Lisa M. Kuhns

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.

Social Integration and Health: Community Involvement, Stigmatized Identities, and Sexual Risk in Latino Sexual Minorities

The purpose of this study is to contribute to the conceptual understanding and practical application of social integration theory to health behaviors. We test whether community involvement in AIDS and GLBT organizations moderates the relationship of racial and homosexual stigmata to sexual risk behavior among gay and bisexual men and transgender persons of Latin American origin or descent. We use structural equation modeling to analyze data from a sample of 643 individuals recruited via respondent-driven sampling. Among those not involved in community organizations, homosexual and racial stigmata are related to sexual activity under the influence of alcohol and drugs, which is linked to sexual risk behavior. Among the involved group, the stigmata are not linked to sexual activity under the influence of alcohol and drugs, or to sexual risk behavior. The moderating role of community involvement seems to be more salient in those currently involved than those ever involved.

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.

The Role of Geographic and Network Factors in Racial Disparities in HIV Among Young Men Who have Sex with Men: An Egocentric Network Study

The objective of this study was to characterize and compare individual and sexual network characteristics of Black, White, and Latino young men who have sex with men (YMSM) as potential drivers of racial disparities in HIV. Egocentric network interviews were conducted with 175 diverse YMSM who described 837 sex partners within 167 sexual-active egos. Sexual partner alter attributes were summarized by ego. Descriptives of ego demographics, sexual partner demographics, and network characteristics were calculated by race of the ego and compared. No racial differences were found in individual engagement in HIV risk behaviors or concurrent sexual partnership. Racial differences were found in partner characteristics, including female gender, non-gay sexual orientations, older age, and residence in a high HIV prevalence neighborhood. Racial differences in relationship characteristics included type of relationships (i.e., main partner) and strength of relationships. Network characteristics also showed differences, including sexual network density and assortativity by race. Most racial differences were in the direction of effects that would tend to increase HIV incidence among Black YMSM. These data suggest that racial disparities in HIV may be driven and/or maintained by a combination of racial differences in partner characteristics, assortativity by race, and increased sexual network density, rather than differences in individual’s HIV risk behaviors.

Project exhale: Preliminary evaluation of a tailored smoking cessation treatment for HIV-positive African American smokers

This study examined the feasibility, acceptability, and outcomes of a culturally tailored smoking cessation intervention for HIV-positive African American male smokers. Eligible smokers were enrolled in a seven-session group-based treatment combined with nicotine patch. The mean age of participants was M=46 years. The majority were daily smokers (71%), smoked a mentholated brand (80%), and averaged 8.6 (standard deviation [SD]=8.1) cigarettes per day. Baseline nicotine dependency scores (M=5.8) indicated a moderate to high degree of physical dependence. Of the 31 participants enrolled, the majority completed treatment (≥3 sessions; 68%), 1-month follow-up (74%), and 3-month follow-up (87%) interviews. Program acceptability scores were strong. However, adherence to the patch was low, with 39% reporting daily patch use. The majority of participants (80%, n=24) made a quit attempt. Furthermore, over the course of the intervention, smoking urge, cigarettes smoked, nicotine dependence, withdrawal symptoms, and depression scores all significantly decreased. Follow-up quit rates at 1 and 3 months ranged from 6% to 24%, with treatment completers having better outcomes. This first of its kind intervention for HIV-positive African American male smokers was feasible, acceptable, and showed benefit for reducing smoking behaviors and depression scores. Smoking cessation outcomes were on par with other similar programs. A larger trial is needed to address limitations and to confirm benefits.

The impact of role models on health outcomes for lesbian, gay, bisexual, and transgender youth.

PURPOSE There is little research on the impact of role models on health outcomes for lesbian, gay, bisexual, and transgender (LGBT) youth. This exploratory study describes the presence and availability of LGBT-affirming role models, and examines the relationship between the accessibility of role models and health outcomes among a community-based sample of LGBT youth. METHODS A convenience sample of 496 ethnically diverse, 16-24-year-old LGBT youth was recruited to complete a computer-assisted interview, using standardized instruments validated with adolescents. The prevalence and characteristics of role models were described. Differences in subgroup distribution were assessed using Pearson χ(2) test (p < .05). Differences in health outcomes for those with and without role models and the nature of those role models were determined using analysis of covariance models, with post hoc Bonferroni tests to probe significant global findings. RESULTS Sixty percent of the participants reported having a role model, with younger participants significantly more likely to report having a role model. A majority of the participants reported having inaccessible role models, especially among younger participants. The presence and accessibility of a role model did not have a significant relationship to binge drinking, drug use, or sexually transmitted infection diagnoses; however, participants with inaccessible role models showed increased psychological distress versus those with accessible or no role models. CONCLUSIONS Inaccessible role models may not be sufficient for protecting youth from negative outcomes, and formal mechanisms for connecting LGBT youth with caring adults who can serve as role models, such as mentoring programs, are critical.

Incidence of HIV infection and sexually transmitted infections and related risk factors among very young men who have sex with men

Introduction:The HIV epidemic continues to disproportionately affect men who have sex with men (MSM) in the United States, with over a third of new infections in MSM occurring in younger men. Very few studies have reported on HIV and sexually transmitted infection (STI) incidence and related risks among younger MSM, particularly among minors under 18 years of age. Methods:Data analyzed herein are from a longitudinal study of HIV risk among 450 very young MSM in Chicago aged 16 to 20, recruited via respondent-driven sampling and followed-up for 2 years, with annual HIV and STI testing. We report estimated cumulative HIV and STI incidence over the 24-month follow-up using Kaplan–Meier methods and evaluated associations with incident infections using Cox proportional hazards regression. Results:The final analytic sample was primarily non-white (83%); median age was 19; 25% of the sample was under age 18. Twenty-six new HIV infections were detected over 632 person-years of follow-up. HIV incidence was 4.11/100 person-years [95% confidence interval (CI): 2.80 to 6.04] and STI incidence was 6.22/100 person-years (95% CI: 4.54 to 8.51). Cumulative HIV incidence over 24 months of follow-up was 7.32% (95% CI: 5.05 to 10.57), with higher incidence among racial/ethnic minorities. In multivariate analyses, non-white race and recent sexual partner concurrency were associated with both HIV and STI infection; HIV testing history and sex with an HIV-positive partner were associated with increased risk of HIV infection. Discussion:High rates of incident HIV infection and STIs among very young MSM and the relationship between incidence and race/ethnicity, concurrency and partner characteristics indicate potential focal points of future intervention and the need for continued vigilance.

Addressing HIV Knowledge, Risk Reduction, Social Support, and Patient Involvement Using SMS: Results of a Proof-Of-Concept Study

Men who have sex with men continue to be severely and disproportionately affected by the HIV/AIDS epidemic in the United States. Effective antiretroviral therapy has altered the HIV epidemic from being an acute disease to a chronic, manageable condition for many people living with HIV. The pervasiveness, low cost, and convenience of short message service suggests its potential suitability for supporting the treatment of conditions that must be managed over an extended period. The purpose of this proof-of-concept study was to develop, implement, and test a tailored short message service–based intervention for HIV-positive men who have sex with men. The messages focused on reducing risk-taking behaviors and enhancing HIV knowledge, social support, and patient involvement. Participants reported strong receptivity to the messages and the intervention. The authors detected a statistically significant increase in HIV knowledge and social support from baseline to follow-up. Among participants who received sexual risk reduction messages, the authors also detected a statistically significant reduction in reported risk behaviors from baseline to follow-up. Results confirm the feasibility of a tailored, short message service–based intervention designed to provide ongoing behavioral reinforcement for HIV-positive men who have sex with men. Future research should include a larger sample, a control group, multiple sites, younger participants, and longer term follow-up.

Texting and Mobile Phone App Interventions for Improving Adherence to Preventive Behavior in Adolescents: A Systematic Review

Background Many preventable behaviors contribute to adolescent mortality and morbidity. Non-adherence to preventive measures represents a challenge and has been associated with worse health outcomes in this population. The widespread use of electronic communication technologies by adolescents, particularly the use of text messaging (short message service, SMS) and mobile phones, presents new opportunities to intervene on risk and preventive risk behavior, but little is known about their efficacy. Objective This study aimed to systematically evaluate evidence for the efficacy of text messaging and mobile phone app interventions to improve adherence to preventive behavior among adolescents and describe intervention approaches to inform intervention development. Methods This review covers literature published between 1995 and 2015. Searches included PubMed, Embase, CENTRAL, PsycINFO, CINAHL, INSPEC, Web of Science, Google Scholar, and additional databases. The search strategy sought articles on text messaging and mobile phone apps combined with adherence or compliance, and adolescents and youth. An additional hand search of related themes in the Journal of Medical Internet Research was also conducted. Two reviewers independently screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Included studies reflect original research—experimental or preexperimental designs with text messaging or mobile phone app interventions—targeting adherence to preventive behavior among adolescents (12-24 years old). The preferred reporting items of systematic reviews and meta-analyses (PRISMA) guidelines were followed for reporting results, and findings were critically appraised against the Oxford Centre for Evidence-based Medicine criteria. Results Of 1454 records, 19 met inclusion criteria, including text messaging (n=15) and mobile phone apps (n=4). Studies targeted clinic attendance, contraceptive use, oral health, physical activity and weight management, sun protection, human papillomavirus (HPV) vaccination, smoking cessation, and sexual health. Most studies were performed in the United States (47%, 9/19), included younger adolescents (63%, 12/19), and had sample size <100 (63%, 12/19). Although most studies were randomized controlled trials (RCTs; 58%, 11/19), only 5 followed an intent-to-treat analysis. Only 6 of 19 studies (32%) incorporated a theoretical framework in their design. Most studies reported good feasibility with high acceptability and satisfaction. About half of the included studies (42%, 8/19) demonstrated significant improvement in preventive behavior with moderate standardized mean differences. As early efforts in this field to establish feasibility and initial efficacy, most studies were low to moderate in quality. Studies varied in sample size and methods of preventive behavior adherence or outcome assessment, which prohibited performing a meta-analysis. Conclusions Despite the promising feasibility and acceptability of text messaging and mobile phone apps in improving preventive behavior among adolescents, overall findings were modest in terms of efficacy. Further research evaluating the efficacy, effectiveness, and cost-effectiveness of these intervention approaches in promoting preventive behavior among adolescents is needed.