Glenn J. Wagner

Pathways through which advocacy training enhances engagement in advocacy among persons living with HIV (PLWH) are not well understood. In a secondary analysis from a randomized controlled trial of a peer advocacy training intervention for PLWH, we examined mediators of intervention effects on HIV prevention advocacy (i.e., encouraging others to engage in HIV protective behaviors) across members of their social network. A sample of 210 PLWH (105 in each of the intervention and control arms) provided information about their advocacy to their social network members at baseline, and 6-, 12-, and 18-month follow-up. Repeated measures linear regressions showed that PLWH in the intervention group targeted more social network members with advocacy for HIV testing, condom use, pre-exposure prophylaxis (PrEP) use, HIV care, and ART use over the follow-up period compared to those in the control group. In path analysis that examined each mediator in a separate model, reduced internalized HIV stigma and increased HIV knowledge as measured at month 6, each fully mediated the intervention effect on HIV care advocacy; reduced stigma partially mediated the effects on advocacy targeting each of the other four HIV protective behaviors, while increased knowledge partially mediated effects on HIV testing, condom and PrEP use advocacy. Results were unchanged when examining the joint mediation of stigma and knowledge. HIV disclosure and advocacy self-efficacy had no mediating effect. These findings highlight the importance of helping PLWH to cope with HIV stigma and gain knowledge about basic facts and common misconceptions related to HIV, to propel their engagement in advocacy for multiple HIV protective behaviors within their social networks. The trial was registered 2021-10-18 (NCT05098015).

Transgender and nonbinary (trans) individuals experience high rates of intimate partner violence (IPV), contributing to elevated vulnerability to human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). While prior research has established associations between IPV and HIV risk, little is known about the mechanisms through which IPV affects engagement in HIV/STI prevention among trans populations. This study qualitatively explored how varied experiences of IPV may impact prevention behaviors, including pre-exposure prophylaxis (PrEP) use, condom negotiation, and HIV/STI testing, within the broader context of structural and interpersonal inequities. We conducted semi-structured interviews with 32 racially and ethnically diverse trans participants who reported IPV in a prior relationship and with 10 key informants who had experience working with this population. Interviews explored experiences of IPV, sexual health decision-making, and barriers to accessing sexual health services. Transcripts were analyzed using applied thematic analysis. Coding combined deductive and inductive approaches, and intercoder agreement was established through team consensus. Four major themes were identified: (1) partner directly interfering with HIV/STI prevention, in which abusive partners restricted access to PrEP, condoms, or HIV/STI testing as a form of control; (2) fear of partner reactions interfering with prevention engagement, where anticipated conflict or violence led survivors to avoid sexual health discussions or care; (3) structural barriers shaping sexual health and safety, highlighting how poverty, stigma, and lack of affirming care compounded IPV-related risks; and (4) gaps in services and suggestions for improvement, emphasizing the need for trauma-informed, gender-affirming, and community-driven interventions in this area. Findings illustrate how IPV may undermine HIV/STI prevention through both direct partner interference and indirect mechanisms rooted in fear, control, and systemic inequity. Addressing these barriers will require a combination of integrated, affirming, trauma-informed, and community-driven interventions that link IPV support with affirming sexual health services along with an expansion of existing IPV services to address the needs of trans people.

Background: Peer advocacy has been shown to influence HIV protective behaviors, but few studies have examined whether advocacy within social networks is diffused—a process whereby the recipient of advocacy engages in further advocacy with others. Advocacy diffusion is critical for wide dissemination of knowledge and behavioral change throughout a network. Method: In a randomized controlled trial of a peer advocacy training intervention for people living with HIV (PLWH) in urban Uganda, 210 PLWH were enrolled as index participants along with 599 of their social network members (alter participants), all of whom were assessed at baseline and months 6, 12 and 18. Prevention advocacy engagement was assessed with a 10-item scale of frequency of discussion of various HIV prevention topics with others in the past 3 months. Repeated-measures linear regression models examined predictors of change in HIV prevention advocacy engagement among 596 alters who completed at least one follow-up assessment. Results: Alter engagement in HIV prevention advocacy increased significantly across follow-up (from 2.08 at baseline to 3.53 at month 18; possible range: 1–5), and this increase was predicted by general increased engagement in advocacy reported by the index participant who recruited them, receipt of any behavior-specific advocacy from this index, older age, and greater HIV disclosure (if the alter was living with HIV). Conclusion: These findings provide evidence of an initial step of HIV prevention advocacy diffusion from index to first-degree alter, thereby highlighting the possibility of diffusion throughout the wider network and the potential for scaled-up dissemination of knowledge and behavior change for HIV prevention.

Reduction of internalized HIV stigma is key to increasing HIV disclosure and engagement in peer advocacy for HIV prevention—and these latter processes may also be important for making further inroads into minimizing stigma. We examined mediators of the effect of a peer advocacy training intervention, Game Changers for HIV Prevention (GC-HIV), on reduced internalized HIV stigma among persons living with HIV (PLWH) in Uganda. A randomized controlled trial was conducted with 210 PLWH (105 in each of the intervention and usual care control arms) who were assessed at baseline and months 6, 12 and 18. Internalized HIV stigma was measured with the 6-item Internalized AIDS-Related Stigma Scale. A repeated measures linear regression model found an intervention effect on reduced internalized HIV stigma. Path analysis performed for each mediator separately revealed that this stigma reduction effect was partially mediated with significant indirect effects for increased HIV disclosure [beta (SE) = − 0.05 (0.03); p = .046] and increased prevention advocacy [beta (SE) = − 0.12 (0.05); p = .01], as well as a significant direct effect; inclusion of both these mediators in the model did not alter this result. HIV knowledge did not act as a mediator of the intervention effect on stigma. Findings support not only the value of the intervention for reducing internalized stigma, but also the benefits of HIV disclosure and encouraging others to protect against HIV for stigma reduction and self-acceptance for PLWH. Clinicaltrials.gov registration (NCT05098015), 2021-10-18.

Sexual minority men (SMM)’s experiences of intimate partner violence (IPV) are a unique and understudied area of study, especially with regard to financial dependence. We explored how power imbalances within couples are associated with IPV victimization and perpetration among SMM, specifically with regard to relationship power dynamics in daily decision-making in couples and financial dependence. Of 423 participants, 33.8% reported experiencing IPV victimization (repeated:21.0%) and 24.3% reported perpetrating IPV (repeated:14.9%). Repeated IPV perpetration was more prevalent among participants who held more power in daily decision-making, while those with partners with greater power were more likely to experience IPV victimization at least once. On the other hand, any type of financial dependence, whether one-way or mutual, was associated with higher likelihood of both IPV victimization and perpetration, challenging assumptions that only dependence on a partner is associated with IPV victimization. These results highlight the critical role of relationship power dynamics and financial dependence in shaping IPV risk among SMM. Our findings underscore the need for more nuanced approaches to understanding economic dynamics in SMM relationships and for public health and clinical strategies that address the complex intersections of power dynamics, financial dependence and IPV.

We examined mediators of the association between intimate partner violence (IPV) and mental health among 500 HIV-negative cisgender sexual minority men (SMM) residing across the United States—a population disproportionately impacted by depression and post-traumatic stress disorder (PTSD). Depressive symptoms were measured with the Patient Health Questionnaire (PHQ-8) and PTSD symptoms with the Primary Care PTSD Checklist (PC-PTSD-5). Forty percent (n = 20) of the sample reported any IPV (victimization or perpetration) in the past 6 months. IPV (represented by mean number of IPV domains with at least one behavior that occurred more than once) was positively correlated with symptoms of depression and PTSD, and these associations were partially mediated (both direct and indirect effects were statistically significant) by social support, coping self-efficacy, substance use consequences, and sexual orientation discrimination; relationship communication partially mediated the association between IPV and depressive symptoms. These findings highlight the strength of the direct association between IPV and mental health for SMM. While the psychosocial and relationship characteristics studied in this analysis may help inform strategies for helping SMM to manage stress related to IPV, multicomponent interventions that address both direct and indirect pathways are likely needed.

Attitudes toward and use of pre-exposure prophylaxis (PrEP) by coupled sexual minority men (SMM) may be influenced by exposure to intimate partner violence (IPV) and sexual agreements regarding non-monogamy. We examined IPV (victimization and perpetration) persistence over 12 months and its association with HIV prevention behaviors and attitudes among 271 coupled, HIV-negative SMM, and the moderating role of sexual agreements. The sample had diverse race/ethnicity (64% were non-White) and was from across all regions of the USA. Participants completed a self-administered, Web-based survey at baseline, 6 months, and 12 months, and reported having the same main partner throughout. Repeated measures regression analysis showed that the level of IPV persistence was unrelated to PrEP use; however, persistent (i.e., present at all three assessments) IPV victimization and perpetration both predicted lower perceived partner support for PrEP use among those not using PrEP, as well as greater PrEP stigma. Persistent IPV victimization and perpetration were both predictive of more frequent HIV testing. The presence of a sexual agreement for non-monogamy (i.e., sex outside the primary relationship), which was a significant independent predictor of more HIV testing and PrEP use, moderated the relationships between IPV and HIV testing and partner support for PrEP, albeit in mixed ways: In non-monogamous relationships, persistent IPV victimization and perpetration were both associated with less HIV testing, but greater perceived partner support for PrEP use. In one of the first longitudinal studies of IPV and HIV prevention among SMM, these findings suggest a complex and nuanced influence of IPV on HIV prevention behaviors and attitudes and the key role that open communication and agreements related to extradyadic sex partners may have for HIV prevention among coupled SMM.

Depression among women living with HIV affects their psychological well-being, HIV disease management, and prevention of mother-to-child transmission. A subset of 25 women selected from the intervention arm of the Maternal Depression Treatment in HIV (M-DEPTH) cluster randomized trial were interviewed; they had received either antidepressant therapy (ADT) or problem-solving therapy (PST). Their experiences as new mothers with the effects of depression and treatment on HIV disease and pregnancy management were assessed in a brief qualitative interview conducted in 2022. Seven were treated with ADT, 15 with PST, and three received both treatment modalities; all but two (n=23) responded to depression treatment. Participants reported improved adherence to HIV antiretroviral therapy and described the treatment as being effective in alleviating depressive symptoms. Additionally, the process of treatment helped them to learn a lot about depression, mental health, and its connection to physical and emotional well-being. Participants also reported improvements in parenting and pregnancy management. The results highlight the need for greater prioritization of mental health care for women living with HIV to prevent poor mental health outcomes and enhance overall functioning, including management of HIV disease, pregnancy, and parenting.

Background: Transgender and nonbinary (TNB) individuals experience intimate partner violence (IPV) at twice the rates of cisgender populations. Although prior research has linked IPV to elevated HIV risk and vulnerability among TNB persons, there is limited understanding of how IPV influences key HIV prevention behaviors, such as HIV and sexually transmitted infection (STI) testing, and initiation and use of pre-exposure prophylaxis (PrEP). IPV experiences among TNB individuals are complex and diverse, varying by type, frequency, severity, and power and relationship dynamics, and often intersect with systemic forms of marginalization. Additional research is needed to investigate the mechanisms linking IPV and HIV outcomes to inform effective, tailored prevention strategies. Objective: This prospective mixed methods cohort study seeks to advance understanding of the risk and protective pathways between IPV (both perpetration and victimization) and HIV-related outcomes, including engaging in condomless sex, STI acquisition, PrEP uptake, adherence, and persistence among TNB individuals experiencing IPV. Methods: This study includes two sequential phases. Phase 1 consisted of formative qualitative interviews with 32 TNB individuals with recent IPV experience and 10 key informants (eg, service providers and advocates) in the United States. These interviews informed the design of a national, web-based cohort study. Phase 2 will enroll 600 HIV-negative, currently partnered TNB participants living in the United States. Participants will be followed for 24 months, with surveys and at-home biospecimen collection (HIV and STI testing and PrEP adherence) at baseline, 6, 12, 18, and 24 months. Brief surveys assessing changes in key variables will also be completed at 3, 9, 15, and 21 months. Results: Phase 1 was initiated in October 2023, with interviews conducted through October 2024 until thematic saturation was reached. Rapid qualitative analysis was completed between November 2024 and January 2025 to inform measurement selection for the phase 2 surveys. Enrollment for phase 2 began in February 2025 and is expected to continue through December 2025. Conclusions: This study will provide essential insights into how IPV impacts HIV risk and prevention practices among TNB individuals. Results will guide the development or refinement of gender-affirming, trauma-responsive, and culturally grounded IPV and HIV prevention interventions tailored to the needs of TNB communities. International Registered Report Identifier (IRRID): DERR1-10.2196/82090