Sean Cahill

Growing Older With HIV/AIDS: New Public Health Challenges

At present, the health care infrastructure is ill-equipped to handle the unique treatment and care needs of HIV-positive older adults. The long-term effects of antiretroviral use are still being discovered and have been associated with a number of comorbidities. Stigma presents challenges for those in need of services and health care, and can significantly affect mental health and treatment adherence. The training of elder service providers and health care providers in meeting the needs of HIV-positive older adults, including gay and transgender people, is needed as the population ages. HIV-related and antigay stigma should be challenged by social marketing campaigns. Continued research and key policy changes could greatly improve health outcomes for HIV-positive elderly persons by increasing access to treatment and support.

School Experiences of Gay, Lesbian, Bisexual and Transgender Youth

Abstract Gay, lesbian, bisexual, and transgender (GLBT) youth are coming out at younger ages, but schools have not changed as fast as the culture, leaving many youth isolated and at risk of violence and harassment. For GLBT youth of color, these problems are exacerbated by racism and the risk of rejection by their ethnic community. Children of GLBT parents are also commonly targeted and harassed by peers. Often ignored or underplayed, however, are the strength, resiliency, and extensive self-advocacy of GLBT youth. This essay summarizes what is known to date about the school experiences of GLBT youth.

Legal Protections in Public Accommodations Settings: A Critical Public Health Issue for Transgender and Gender-Nonconforming People

POLICY POINTS Since 2012, Massachusetts law has provided legal protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not protect against discrimination based on gender identity in public accommodations settings such as transportation, retail stores, restaurants, health care facilities, and bathrooms. A 2013 survey of Massachusetts transgender and other gender minority adults found that in the past 12 months, 65% had experienced public accommodations discrimination since the law was passed. This discrimination was associated with a greater risk of adverse emotional and physical symptoms in the past 30 days. Nondiscrimination laws inclusive of gender identity should protect against discrimination in public accommodations settings to support transgender peoples health and their ability to access health care. CONTEXT Gender minority people who are transgender or gender nonconforming experience widespread discrimination and health inequities. Since 2012, Massachusetts law has provided protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not, however, protect against discrimination in public accommodations (eg, hospitals, health centers, transportation, nursing homes, supermarkets, retail establishments). For this article, we examined the frequency and health correlates of public accommodations discrimination among gender minority adults in Massachusetts, with attention to discrimination in health care settings. METHODS In 2013, we recruited a community-based sample (n = 452) both online and in person. The respondents completed a 1-time, electronic survey assessing demographics, health, health care utilization, and discrimination in public accommodations venues in the past 12 months. Using adjusted multivariable logistic regression models, we examined whether experiencing public accommodations discrimination in health care was independently associated with adverse self-reported health, adjusting for discrimination in other public accommodations settings. FINDINGS Overall, 65% of respondents reported public accommodations discrimination in the past 12 months. The 5 most prevalent discrimination settings were transportation (36%), retail (28%), restaurants (26%), public gatherings (25%), and health care (24%). Public accommodations discrimination in the past 12 months in health care settings was independently associated with a 31% to 81% increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care, adjusting for discrimination in other public accommodations settings (which also conferred an additional 20% to 77% risk per discrimination setting endorsed). CONCLUSIONS Discrimination in public accommodations is common and is associated with adverse health outcomes among transgender and gender-nonconforming adults in Massachusetts. Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities.

Community-based HIV prevention interventions that combat anti-gay stigma for men who have sex with men and for transgender women.

Men who have sex with men (MSM) have been disproportionately affected by HIV since the onset of the epidemic. Public health discourse about prevention has traditionally focused on individual risk behavior and less on the socio-structural factors that place MSM at increased risk of infection. Anti-gay bias and stigma are key structural drivers of HIV and must therefore be treated as a public health threat. Community-based prevention intervention programs that affirm the healthy formation of gay and transgender identities are strongly needed. Gay affirming school-based interventions and resiliency-focused social marketing campaigns have shown positive impact on health outcomes and should be implemented on a broader scale to challenge anti-gay stigma.

Service Utilization Among Older Adults With HIV: The Joint Association of Sexual Identity and Gender

This study examines the association of sexual identity and gender among older clients with HIV at an AIDS service organization using the Andersen Model. Data confirm those aging with HIV exhibit high rates of age-associated illnesses 10 to 20 years before expected. They have fragile social networks that cannot supply the informal supports needed. This aging population will need to increasingly access community-based services. Sexual identity and gender were weak covariates of service utilization. Although heterosexual men used more services, utilization was largely predicted by service needs and the use of case management. Implications for service delivery and policy are discussed.

At the Intersection of HIV/AIDS and Cancer: A Qualitative Needs Assessment of Community-Based HIV/AIDS Service Organizations

Due to advances in treatment, persons living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) are living longer, but with aging, immune deficits, and lifestyle factors, they are at increased risk for cancer. This challenges community-based AIDS service organizations (ASOs) to address the growing cancer needs of persons living with HIV/AIDS (PLWHA). Community-based participatory research was applied to engage ASOs in exploring their capacities and needs for integrating cancer-focused programming into their services. Focus groups were conducted with a community advisory board (CAB) representing 10 community-based organizations serving PLWHA. Three 90-minute, serial focus groups were conducted with a mean number of seven participants. Topics explored CAB members’ organizational capacities and needs in cancer prevention, detection, treatment, and survivorship. Transcript analyses identified six themes: (a) agencies have limited experience with cancer-focused programs, which were not framed as cancer specific; (b) agencies need resources and collaborative partnerships to effectively incorporate cancer services; (c) staff and clients must be educated about the relevance of cancer to HIV/AIDS; (d) agencies want to know about linkages between HIV/AIDS and cancer; (e) cancer care providers should be culturally competent; and (f) agencies see opportunities to improve their services through research participation but are wary. Agency capacities were strong in relationships with clients and cultural competency, a holistic view of PLWHA health, expertise in prevention activities, and eagerness to be on the cutting edge of knowledge. Cancer education and prevention were of greatest interest and considered most feasible, suggesting that future projects develop accordingly. These findings suggest a high level of receptivity to expanding or initiating cancer-focused activities but with a clear need for education and awareness building. Qualitative findings will inform a large quantitative survey to validate identified themes, which will be applied in developing interventions to assist ASOs in adopting or expanding cancer-focused activities.

A State-Level Review of Diversity Initiatives in Congregate Meal Programs Established Under the Older Americans Act:

The Older Americans Act (OAA) congregate meal program (CMP) targets those most at risk for nutritional deficiencies, social isolation, and institutionalization. Social minorities (racial, ethnic, cultural, and sexual minorities) are at high risk for all three. This study explores state-level diversity initiatives to welcome these social minorities in CMPs. A national survey was distributed to each State Unit on Aging, all but three states participated. The majority of states (64.6%) target CMPs to a specific racial, ethnic, or cultural minority; five states target sexual minorities (lesbian, gay, bisexual, and transgender [LGBT]). Negative binomial regression results find state minority population percentage is a significant predictor of the number of diversity initiatives at CMPs. States with LGBT CMPs reported the highest levels of racial/ethnic/cultural diversity initiatives and high levels of statewide LGBT protective policies. Recommendations are suggested that build upon the diversification success of states to further the mission of OAA in reaching high-risk older adults.

HIV Positive Gay Men, Health Care, Legal Rights, and Policy Issues

Gay men living with HIV have complex health care needs involving physical and mental health and comorbidities with other health conditions. The health disparities affecting gay men must be understood in the context of macro-level processes. A life-course framework along with the constructs of minority stress and resiliency will be examined in understanding the health of gay men. Aging and caregiving issues for HIV positive gay men will be explored. The concept of Treatment as Prevention will be examined, along with biomedical prevention technologies that can help HIV negative partners in serodiscordant couples remain negative. Legal issues such as criminalization and discrimination will be considered. Myriad recent changes in health policy will be addressed, including the expanded access to both private and public health insurance through the Affordable Care Act. The experiences of HIV positive gay men in the Veterans Administration system and in senior settings will also be examined, as well as policy changes that can better equip these systems to provide clinically competent care.

Priorities for Public Health Spending

with the RAES in identifying trainees who demonstrate inadequate professionalism. First, what was the trajectory of scores in subsequent years among trainees with low scores on professionalism during the first year? Second, did the third-year trainees who scored poorly on milestones for professionalism have similar assessment by the RAES? The assessments should be highly correlated. If milestones produced more low scores in year 3 than the RAES, then examination of the 4 subcompetencies comprising the professionalism competency might indicate whether milestones are indeed capturing more information.