Sandra A. Kupprat

Evaluation of the Relative Effectiveness of Three HIV Testing Strategies Targeting African American Men Who Have Sex with Men (MSM) in New York City

BackgroundAfrican American men who have sex with men (MSM) are disproportionately affected by HIV and constitute more than half of all HIV-infected MSM in the USA.PurposeData from the New York City location of a multi-site study were used to evaluate the effectiveness of three HIV testing strategies for detecting previously undiagnosed, 18 to 64-year-old African American MSM. Effectiveness was defined as the identification of seropositive individuals.MethodsUsing a quasi-experimental design (N = 558), we examined HIV-positive test results for men tested via alternative venue testing, the social networks strategy, and partner counseling and referral services, as well as behavioral risk factors for 509 men tested through alternative venue testing and the social networks strategy.ResultsDetection rates of HIV-positives were: alternative venue testing—6.3%, the social networks strategy—19.3%, and partner services—14.3%. The odds for detection of HIV-positive MSM were 3.6 times greater for the social networks strategy and 2.5 times greater for partner services than alternative venue testing. Men tested through alternative venue testing were younger and more likely to be gay-identified than men tested through the social networks strategy. Men who tested through the social networks strategy reported more sexual risk behaviors than men tested through alternative venue testing.ConclusionsFindings suggest differential effectiveness of testing strategies. Given differences in the individuals accessing testing across strategies, a multi-strategic testing approach may be needed to most fully identify undiagnosed HIV-positive African American MSM.

Sexual Risk Taking in Relation to Sexual Identification, Age, and Education in a Diverse Sample of African American Men Who Have Sex with Men (MSM) in New York City

HIV disproportionately affects African American men who have sex with men (MSM) in the United States. To inform this epidemiological pattern, we examined cross-sectional sexual behavior data in 509 African American MSM. Bivariate logistic regression analyses were conducted to examine the extent to which age, education, and sexual identity explain the likelihood of engaging in sex with a partner of a specific gender and the likelihood of engaging in unprotected sexual behaviors based on partner gender. Across all partner gender types, unprotected sexual behaviors were more likely to be reported by men with lower education. Younger, non-gay identified men were more likely to engage in unprotected sexual behaviors with transgender partners, while older, non-gay identified men were more likely to engage in unprotected sexual behaviors with women. African American MSM do not represent a monolithic group in their sexual behaviors, highlighting the need to target HIV prevention efforts to different subsets of African American MSM communities as appropriate.ResumenEn los Estados Unidos el VIH afecta desproporcionadamente a los hombres Afroamericanos que tienen sexo con otros hombres. Para explorar este patrón epidemiológico, examinamos transversalmente la conducta sexual de 509 hombres Afroamericanos que tienen sexo con otros hombres. Se realizó un análisis de regresión logística binaria para examinar en qué medida la edad, la educación, y la identidad sexual explicarían la probabilidad de tener relaciones sexuales con una pareja de un género específico y la probabilidad de tener relaciones sexuales sin protección basada en el género de la pareja. Independientemente del genero de la pareja (hombres, mujeres, y transgénero), el tener relaciones sexuales sin protección fue reportado más frecuentemente por hombres con menor educación formal. Los hombres más jóvenes y que no se identifican como gay tuvieron una mayor probabilidad de reportar relaciones sexuales sin protección con parejas transgénero. Mientras que los hombres más viejos y que no se identifican como gay tuvieron una mayor probabilidad de reportar relaciones sexuales sin protección con mujeres. Los hombres Afroamericanos que tienen sexo con otros hombres no representan un grupo monolítico en sus relaciones sexuales, destacando la necesidad de dirigir los esfuerzos de prevención del VIH en modo específico a diferentes subgrupos de estas comunidades.

Psychosocial burdens negatively impact HIV antiretroviral adherence in gay, bisexual, and other men who have sex with men aged 50 and older.

We sought to characterize HIV antiretroviral therapy (ART) adherence and psychosocial correlates of adherence in a sample of gay, bisexual, and other non-gay or -bisexual identified men who have sex with men aged 50 and over. As part of a cross-sectional study we recruited a community-based sample of 199 men and assessed adherence to current ART medications along four domains: (1) missing doses in the past 4 days, (2) taking doses on the specified schedule in the past 4 days, (3) following instructions about how to take the medications (e.g., to take medications with food), and (4) missing doses in the last weekend. A total adherence score was also computed. Bivariable analyses indicated negative associations between depression, sexual compulsivity, and HIV-related stigma with each of the individual adherence variables and the composite adherence score, while an older age was found to be protective. In multivariable analyses, controlling for age and educational attainment, a higher likelihood of missing doses and failing to follow instructions were related to higher levels of HIV-related stigma, while dosing off-schedule and missing doses on weekends was associated with higher levels of sexual compulsivity. These results indicate that psychosocial burdens undermine the adherence behaviors of older HIV-positive sexual minority men. Programming and services to address this compromising health behavior must embrace a holistic approach to health as informed by syndemics theory, while attending to the developmental and age-specific needs of older men.

HIV-Related Stigma as a Mediator of the Relation Between Multiple-Minority Status and Mental Health Burden in an Aging HIV-Positive Population

Cross-sectional analyses of 904 diverse men and women aged 50 years and older living with HIV in New York City were conducted to examine the unique experiences and needs of aging HIV-positive individuals. Using Minority Stress Theory and Syndemic Theory as guiding paradigms, the authors documented the mental health burdens of the sample with regard to depression, loneliness, and diminished psychological well-being and examined how multiple-minority status and HIV-related stigma explained these burdens. Mediation modeling demonstrated that the effects of minority stressors on mental health burden were mediated by HIV-related stigma. The mediation was significant for the overall sample and for the male subsample. Results suggest that to fully address the mental health burdens experienced by aging HIV-positive individuals, we must continue to address mental health burdens directly, and at the same time, look beyond the psychiatric symptoms to address the structural inequities faced by individuals based on their multiple-minority status.

Lessons Learned From Use of Social Network Strategy in HIV Testing Programs Targeting African American Men Who Have Sex With Men

OBJECTIVES We report lessons derived from implementation of the Social Network Strategy (SNS) into existing HIV counseling, testing, and referral services targeting 18- to 64-year-old Black gay, bisexual, and other men who have sex with men (MSM). METHODS The SNS procedures used in this study were adapted from a Centers for Disease Control and Prevention-funded, 2-year demonstration project involving 9 community-based organizations (CBOs) in 7 cities. Under the SNS, HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted to identify and recruit persons from their social, sexual, or drug-using networks (network associates) for HIV testing. Sites maintained records of modified study protocols for ascertaining lessons learned. The study was conducted between April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York, and at a health department in Baltimore, Maryland. RESULTS Several common lessons regarding development of the plan, staffing, training, and use of incentives were identified across the sites. Collectively, these lessons indicate use of SNS is resource-intensive, requiring a detailed plan, dedicated staff, and continual input from clients and staff for successful implementation. CONCLUSIONS SNS may provide a strategy for identifying and targeting clusters of high-risk Black MSM for HIV testing. Given the resources needed to implement the strategy, additional studies using an experimental design are needed to determine the cost-effectiveness of SNS compared with other testing strategies.

Case manager-reported utilization of support group, substance use and mental health services among HIV-positive women in New York City

Abstract A retrospective, longitudinal analysis of case management and medical charts was used to evaluate utilization of support group, mental health, and substance abuse treatment services among HIV-positive women in New York City. Analyses of 4134 case management and supportive service transactions revealed that 70% utilized support groups over the two-year study period. In contrast, only 35% utilized mental health services (therapy) and of those identified as using substances, only 48% utilized substance abuse treatment services. Considering the high prevalence of mental illness (63%, n=29) and substance use (54%, n=25) in the sample, the low utilization rates highlight unmet needs for service. Significant differences were found in utilization of mental health and substance abuse treatment services, with those who received services at a medical model agency (integrated care) being more likely to receive both types of treatment. In contrast, participants attending support groups in non-medical model agencies (77.8%, n=7) were significantly more likely to be retained in group (i.e., attend 11 or more sessions) than those at medical model agencies (39.1%, n=9). Based on the higher utilization rates of support groups among seropositive women, perhaps these groups could be a vehicle for establishing rapport between mental health professionals and group members to bridge the utilization gap and reduce the stigma associated with therapy and substance abuse treatment services. These findings both taut the success and highlight weaknesses regarding accessing mental health and substance abuse care, and support group retention. Sharing of information regarding recruitment and retention efforts between agencies of different modalities would be beneficial and also could identify service niches that capitalize on their subsequent strengths.

Longitudinal Associations Between Case Management and Supportive Services Use among Black and Latina HIV-positive Women in New York City

BACKGROUND The literature analyzing the relationship between case management and supportive service use longitudinally among African American and Latina HIV-positive women is limited. METHODS This retrospective analysis of participant case management, supportive service, and medical charts sought to examine both descriptive and relational data on use of case management and supportive services over a 2-year period from 2002 to 2005 and to analyze moderating person- level or institution-level factors. RESULTS The analyzed case management, supportive service, and medical charts revealed that participants interacted with their case manager four times and received 3.6 supportive services per month. Transportation, primary healthcare/medical specialists, and support groups were the services most used, with rates ranging from 70% to 80%. Using hierarchical linear modeling (HLM), the unconditional growth models showed that case management and supportive service use patterns remained constant over the 24-month period. Additionally, the multivariate unconditional model suggests a significant positive relationship between case management and supportive services. No moderation was indicated in the association between case management and supportive service use by person-level (e.g., mental illness, substance use) and institution-level (i.e., service delivery model) factors. CONCLUSIONS Participants use supportive and case management services in a similar manner based on individual need. This synergistic relationship suggests that increases in either may result in retaining women in care. Implications for service delivery point to the need for skills building training for case managers, outreach workers, or system navigators to assist with short-term goals of establishing rapport and maintaining the client relationship, as this may lead to HIV-positive women accessing services. Additionally, outreach and engagement strategies need to be developed for those who typically underuse these services.

Smoking and HIV-related Health Issues among Older HIV-positive Gay, Bisexual, and Other Men Who Have Sex with Men

The prevalence of cigarette smoking and the relations between smoking and HIV clinical markers, HIV medication adherence, and opportunistic infections (OIs) were examined in a sample of 199 HIV-positive, gay, bisexual, and other men who have sex with men (MSM) aged 50 and older. Overall, 35.7% were current smokers, 35.7% were former smokers, and 28.6% were never smokers. In the final multivariable polytomous logistic regression model controlling for age, income, and illicit drug use, current smokers were less likely to report an undetectable viral load as compared to never and former smokers. Relative to never smokers, former smokers were more likely to report respiratory OIs, and current smokers were more likely to report gastrointestinal OIs. This study demonstrates high prevalence of cigarette smoking among aging, HIV-positive MSM and provides additional evidence for a relationship between smoking and poorer HIV clinical markers. Targeted and tailored smoking cessation programs within the context of HIV care services are warranted.

Religiousness, Spirituality, and Existential Well-being Among HIV-Positive Gay, Bisexual, and Other MSM Age 50 and Over

The religious and spiritual experiences of HIV-positive gay, bisexual, and other men who have sex with men (MSM) are severely understudied, especially among those over 50. However, literature supports that religious/spiritual experiences are related to both physical and mental health among older adults. In this exploratory analysis we assessed the relations that exist among a sample of HIV-positive gay, bisexual, and other MSM over 50 in regard to sociodemographic factors and two established measures of religiosity/spirituality. Differences emerged in relation to both race/ethnicity and age for the Ironson-Woods Spirituality/Religiousness (SR) Index, while, for the Existential Well-being subscale, differences emerged in relation to race/ethnicity and perceived socioeconomic status.

Age- and education-matched comparison of aging HIV+ men who have sex with men to general population on common neuropsychological assessments

Little is known about the impact of HIV and aging on cognitive functioning. This New York City cross-sectional study of aging HIV-positive gay and bisexual men assessed their neuropsychological state. Working memory and verbal abstract reasoning were relatively intact. After 55 years of age, attention abilities were impaired. Executive function impairment was present regardless of age and education. Results suggest the need for HIV-specific norms, and the use of neuropsychological assessments (i.e. baseline and over time) as a cost-effective way to assess HIV-related cognitive decline in developed and under-developed countries.