Steven A. Safren

Self-efficacy (SE) is central to sexual health behavior change and may be important for pre-exposure prophylaxis (PrEP) adherence among men who have sex with men (MSM). This study examines factors associated with three PrEP self-efficacy domains: routine adherence (RA), medication management (MM), and overcoming psychosocial challenges (OPC). Three hundred U.S. MSM, who either initiated daily oral PrEP or reported anticipated adherence difficulties, and who all experienced at least one psychosocial syndemic condition, were recruited as part of a randomized controlled trial. Baseline assessments included PrEP SE and psychosocial, structural, and sociodemographic variables. Bayesian variable selection and multiple linear regression identified several predictors. Younger age (RA: b = 0.048, 95% CI [0.025, 0.072]; MM: b = 0.033, 95% CI [0.012, 0.054]; OPC: b = 0.060, 95% CI [0.023, 0.087]) and greater structural barriers (RA: b = − 0.090, 95% CI [-0.151, − 0.029]; MM: b = − 0.192, 95% CI [-0.246, − 0.138]; OPC: b = − 0.145, 95% CI [-0.229, − 0.055]) were associated with decreased SE across all factors ( p < .01). Social anxiety was associated with lower routine adherence SE ( b = − 0.039, 95% CI [-0.063, -0.016], p < .01); lifetime polysubstance use was associated with lower medication management SE ( b = − 0.192, 95% CI [-0.325, -0.058], p < .01); and overseas-born status ( b = − 0.932, 95% CI [-1.759, -0.106], p < .05) and greater sexual compulsivity ( b = − 0.157, 95% CI [-0.269, -0.046], p < .01) were both associated with lower SE in overcoming psychosocial challenges. Findings underscore the need for multilevel, culturally responsive PrEP interventions that promote SE across all three domains.

Clinical or methodological significance of this article: This study developed and validated the LGBTQ Affirmation and Discussion In-Session (LADI) Inventory to measure therapists’ LGBTQ-affirmative...

Background: Miami-Dade County leads in US HIV incidence, with Latino sexual minority men (LSMM) diagnosed with HIV more frequently than any other subgroup. HIV testing is a first step toward linkage to appropriate biomedical prevention or treatment services, therefore maximizing the reach of HIV testing to LSMM is paramount. The purpose of this study was to identify longitudinal determinants associated with recent HIV testing among LSMM in the greater Miami, FL area. Methods: Participants included 234 LSMM who completed a self-report assessment of HIV-prevention service engagement and related measures at baseline, 4- and 8-months. We utilized stochastic search variable selection (SSVS) and hierarchal linear modeling to identify predictors of recent HIV testing. Results: SSVS identified four variables that were then entered into a hierarchal linear model. Over time, participants were significantly more likely to have had a recent HIV test. Three of the four variables identified were significantly associated with recent HIV testing: knowing people who had a recent HIV test, knowledge about HIV, and sexual behavior indicating CDC PrEP eligibility. Conclusions: This study identified multilevel determinants associated with LSMM’s recent HIV testing. At the individual level, HIV testing was influenced by behavioral risk factors related to sexual activity and HIV knowledge. Pertaining to the interpersonal level, knowing people who recently tested for HIV was associated with HIV testing. Multilevel adjunctive interventions and implementation strategies that increase HIV knowledge and leverage peer influence may improve testing uptake among LSMM in the Miami, FL area.

Substance use in general, and stimulant use in particular, among men who have sex with men (MSM) remains an important issue within the field of public health because of its rates of use, its relati...

Introduction: In South Florida, a high-priority region within the federal Ending the HIV Epidemic initiative, a substantial proportion of new HIV diagnoses among Latino men who have sex with men (LSMM) occur in the context of employment-related barriers, language needs, and nativity-related challenges that undermine HIV prevention and care engagement. Methods: We applied the ADAPT-ITT framework to adapt Work2Prevent , an evidence-based “employment as HIV prevention” structural intervention, for Spanish-speaking LSMM born outside of the US. Focus groups with 12 LSMM and 13 topical experts were conducted, and rapid qualitative analysis identified six overarching themes and 15 subthemes to guide intervention adaptations. Results: Participants viewed an adapted Work2Prevent as potentially valuable and unique for LSMM (Theme 1), though proposed modifications to enhance its acceptability and appropriateness, including: (2) centering immigrant and LGBTQ+ worker rights, (3) grounding the intervention in lived experience through language, design, and representation, (4) building foundational skills and flexible pathways to employment, and (5) supporting wellbeing, belonging, and connection. To improve feasibility, participants emphasized (6) developing strategic and flexible implementation models to enhance delivery and reach. Conclusions: The adapted intervention addresses this feedback for future piloting, and the lessons learned and articulated here can be applied to other employment interventions or programs for LSMM addressing this important structural driver of HIV disparities. Policy Implications: Findings underscore the relevance of employment as a social determinant of health in shaping immigration-informed, status-neutral HIV prevention and care approaches for Latino sexual minority men, particularly when grounded in input from community partners.

Background: A substance use disorder (SUD) treatment gap exists globally, with the greatest gaps in settings with the fewest resources. Integrating SUD care into primary care is needed to expand access to SUD care and support adherence to chronic disease services, especially HIV, in high-burden areas. Guided by stakeholder feedback, our team has previously adapted and piloted a peer-delivered behavioral intervention for antiretroviral therapy (ART) adherence for people with HIV and SUD in HIV care (“ Khanya ”)—based on behavioral activation, problem-solving, motivational interviewing, and mindfulness-based relapse prevention skills—which was shown to be feasible, acceptable, and preliminarily effective. Objective: This study builds upon prior work to conduct a fully powered, randomized hybrid type 2 effectiveness-implementation trial (n=160) to evaluate the effectiveness of a stepped-care model of Khanya versus enhanced treatment as usual (ETAU) on ART adherence and substance use, implementation outcomes, and cost-effectiveness over 12 months. Methods: The trial is being conducted at two public primary care clinics that integrate HIV and other chronic disease services in a high-prevalence HIV setting in South Africa. We are recruiting people with HIV who self-report SUD and demonstrate one or more indicators of ART nonadherence. Eligible participants are randomized 1:1 to Khanya or ETAU. Participants randomized to Khanya first receive “step 1”—a single-session Life-Steps intervention for ART adherence delivered by a peer interventionist, followed by 2 weeks of real-time electronically monitored ART adherence using Wisepill to determine step-up decisions (ie, Khanya intervention). The RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework guided outcome measure selection, including effectiveness (ART adherence: Wisepill; substance use: urinalysis and WHO ASSIST [World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test]); implementation (feasibility, acceptability, fidelity, and uptake assessed using 2 validated quantitative measures and qualitative feedback over 6 months); and cost-effectiveness (microcosting, health care use, and health-related quality of life using the EuroQol-5D). Descriptive analysis will be used to summarize implementation outcomes, and intent-to-treat analysis using a linear mixed model will be conducted for effectiveness outcomes. Results: Funded in August 2022, recruitment for the trial began in June 2023, and primary data collection is projected to be completed in February 2027. Recruitment for the clinical trial (n=162) was completed in March 2026. It is projected that all exit interviews will be completed by March 2027. Conclusions: This trial builds upon formative work to evaluate the effectiveness, implementation, and cost of a peer-delivered, stepped care intervention integrated into primary care. A stepped-care design to maximize optimal use of resources and integration into primary care is a necessary step to increase accessible intervention programs for people with HIV with comorbid SUD globally.

Background: Men who have sex with men (MSM) in India face unique psychosocial and HIV-related stressors. Collective self-esteem (CSE) may be a particularly important protective factor for this population given Indian collectivist cultural values. This study examined potential effects of CSE sequentially on individual self-esteem (ISE), depression and, in turn, sexual behavior and health outcomes longitudinally among Indian MSM. Method: Three hundred and one Indian MSM were surveyed at baseline, and at 4, 8, and 12 months. Assessments included the CSE scale, Rosenberg ISE, clinically significant depressive symptoms, condomless anal sex (CAS), and sexually transmitted infections (STIs). After confirmatory factor analysis (CFA) of the CSE scale, path models were estimated to examine longitudinal associations of CSE on outcomes via serial mediation. Results: One of the three collective self-esteem factors from the CFA, public view of group, significantly predicted outcomes. This factor, a higher public view of group, predicted increased ISE 4 months later, which in turn via mediation, predicted fewer clinically significant depressive symptoms at 8 months (B = −0.685, β = −0.048, 95% BCa CI [−1.547, −0.280]). When adding CAS as the outcome at 12 months, ISE at 4 months and depression at 8 months were serial mediators of the effects of public view of group ( B = −0.207, β  = −0.017, 95% BCa CI [−1.086, −0.051]). When adding STI to the model instead of CAS, STI incidence was not predicted. Conclusion: Of the components of collective self-esteem in Indian MSM, public view of group emerged as a key predictor of mental and sexual health in Indian MSM. Addressing collective self-esteem and/or its contributors (e.g., stigma) may have beneficial effects for Indian MSM.

Persons living with HIV (PLWH) are disproportionately exposed to traumatic events, which are associated with posttraumatic psychological distress and impaired HIV-related health outcomes (e.g., antiretroviral non-adherence, HIV viremia, lower CD4 count). Prior literature has not adequately differentiated the effects of trauma and posttraumatic distress on HIV-related health outcomes. This study examined longitudinal data of trauma exposure and posttraumatic psychological distress among PLWH. Participants were 255 PLWH in care at a public HIV clinic that completed baseline and one-year follow-up psychosocial assessments between April 2017 and May 2024. Assessments included measures of lifetime trauma exposure, symptoms of depression, anxiety, and posttraumatic distress, and antiretroviral adherence. HIV RNA viral load and CD4 count were extracted from medical records. Factor analysis was used to consider multifaceted posttraumatic responses. Path analysis was used to examine direct and indirect effects of trauma exposure and posttraumatic distress on HIV-related outcomes. Most participants endorsed lifetime trauma exposure (88.2%). Trauma exposure was associated with increased posttraumatic psychological distress (est.=0.281, p = 0.004). Psychological distress predicted lower antiretroviral adherence (est.=-0.070, p = 0.033), which was associated with higher log HIV RNA viral load (est.=-0.477, p < 0.001) and lower CD4 count (est.=84.754, p < 0.001). Controlling for distress, trauma exposure did not predict HIV-related health outcomes. Trauma exposure was highly prevalent and posttraumatic psychological distress predicted poorer HIV-related health outcomes at follow-up. These findings highlight the need for universal trauma-informed care and the utility of integrated psychological services for those impacted by posttraumatic distress within HIV treatment settings to improve HIV-related health outcomes.