Beyond the Individual: The Roles of Social and Structural Contexts in HIV Prevention and HIV Acquisition in the United States

The present dissertation leverages the utility of analyzing a variety of secondary data sources to explore relationships between qualities of social and structural environments and HIV-related outcomes via a social-ecological approach. Advances in HIV outcomes for vulnerable, high-risk populations, e.g., African-American/Black gay, bisexual, and other men who have sex with men (BMSM), have been stymied by social and behavioral scientists’ tendency to primarily call upon individual-behavioral factors to explain the elevated rates of HIV observed within BMSM communities. This dissertation employs a broader analytical lens to explore relationships between social and structural variables with HIV acquisition and other key HIV-related outcomes (Studies 1 and 2). This dissertation also uses social media data to garner insights about the general public’s understandings of, and attitudes toward, extant HIV prevention tools. Location-based social media data are used to link attitudes toward HIV prevention tools with various social and structural characteristics of the geographic locations from where the content originates (Study 3). The results of the three studies indicate that there are real HIV prevention and acquisition considerations for social- and structural-level variables, such that factors at these levels have significant main and interactive associations with key HIV prevention, HIV risk behavior, and HIV acquisition variables. Taken together, the results indicate that HIV prevention and care strategies should not treat HIV as an independent social problem. Instead, future interventions must be multi-level in nature, with goals of positive behavioral as well as social and structural change

Prevalence and correlates of using opioids alone among individuals in a residential treatment program in Michigan: implications for overdose mortality prevention

Abstract Background Avoiding use of opioids while alone reduces overdose fatality risk; however, drug use-related stigma may be a barrier to consistently using opioids in the presence of others. Methods We described the frequency of using opioids while alone among 241 people reporting daily heroin use or non-prescribed use of opioid analgesic medications (OAMs) in the month before attending a substance use disorder treatment program in the Midwestern USA. We investigated drug use-related stigma as a correlate of using opioids while alone frequently (very often vs. less frequently or never) and examined overdose risk behaviors associated with using opioids while alone frequently, adjusted for sociodemographic and clinical characteristics. Results The sample was a median age of 30 years, 34% female, 79% white, and nearly all (91%) had experienced an overdose. Approximately 63% had used OAMs and 70% used heroin while alone very often in the month before treatment. High levels of anticipated stigma were associated with using either opioid while alone very often (adjusted PR: 1.20, 95% CI: 1.04–1.38). Drinking alcohol and taking sedatives within two hours of OAMs very often (vs. less often or never) and using OAMs in a new setting very often (vs. less often or never) were associated with using OAMs while alone very often. Taking sedatives within two hours of using heroin and using heroin in a new setting very often (vs. less often or never) were associated with using heroin while alone very often. Conclusion Anticipated stigma, polysubstance use, and use in a new setting were associated with using opioids while alone. These findings highlight a need for enhanced overdose harm reduction options, such as overdose detection services that can initiate an overdose response if needed. Addressing stigmatizing behaviors in communities may reduce anticipated stigma and support engagement and trust in these services

Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States

Characterizing Metrics of Sexual Behavior Stigmas Among Cisgender Men Who Have Sex with Men in Nine Cities Across the United States.

Men who have sex with men (MSM) in the United States (US) are stigmatized for same-sex practices, which can lead to risky sexual behavior, potentiating risk for HIV infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to the local surveys of 9 sites of the Centers for Disease Control and Prevention 2017 National HIV Behavioral Surveillance system, which used venue-based, time-sampling procedures to survey cisgender MSM in US metropolitan statistical areas. We performed exploratory factor analytic procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; Virginia Beach-Norfolk, Virginia) and pooled responses to the items. A three-factor solution - stigma from family (α = 0.70), anticipated health-care stigma (α = 0.75), general social stigma (α = 0.66) - best fit the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the US experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking stigma trends over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the US

Additional file 3 of Associations between HIV testing and multilevel stigmas among gay men and other men who have sex with men in nine urban centers across the United States

Additional file 3: Appendix 3 Figure. Conceptual diagram of multivariable generalized hierarchical linear model combining individual and site factors

Additional file 1 of Associations between HIV testing and multilevel stigmas among gay men and other men who have sex with men in nine urban centers across the United States

Additional file 1: Appendix Table 1. Sexual behavior stigma scale items and responses by associated factors