Bryan Andrew Kutner

Stigma toward anal sex hinders HIV prevention by limiting equitable access to sexual health services. To mitigate this hindrance, we developed a clinician- and community-informed package of anti-stigma implementation strategies using the Behaviour Change Wheel and its Capability, Opportunity, Motivation, Behaviour (COM-B) Model. The package, “Partnering to Enhance Anal Health Communication and HIV-related Evidence-based Services” (PEACHES 1.0), combined training strategies with quality improvement (QI) strategies. We implemented a pilot evaluation of PEACHES 1.0 among HIV workers in the Southern USA and assessed pre/post-shifts in participants’ self-reported proximal outcomes (mechanisms of action like knowledge, comfort, skills) and their frequency of anal sex-specific health promotion. In two clinics that received organization-specific QI meetings, we also assessed patient uptake of anal sex-related HIV services based on aggregated medical record data. We conducted paired t -tests on longitudinal survey responses, thematic analysis of longitudinal in-depth interviews and open-ended survey responses, and non-statistical comparison of rates for patient uptake of services. Post-PEACHES, HIV workers reported 8% to 54% improvements (all p < .01) in proximal outcomes like knowledge, comfort, and skills. Frequency of self-reported anal health promotion increased 15% to 25% ( p < .01). Clinics that received QI sessions differed in their QI engagement and had diverging patient uptake of services. Clinic A, with greater QI engagement, saw a 60% increase in anorectal STI screening, and a 28% increase in new PrEP prescriptions; Clinic B, with less engagement, saw 17% and 18% decreases, respectively. Qualitative findings indicated that the QI strategies—placing pleasure-inclusive visual cues linked to a website of informational resources in the clinic environment and clinic-specific QI meetings—enabled workers to destigmatize discussions about anal sex within HIV services. Future research should standardize elements of QI, and evaluate scalability with fidelity as well as the potential impact on client outcomes in a fully-powered hybrid implementation-effectiveness trial.

Background: HIV counseling support staff (CSS) play a crucial role in HIV care outcomes, providing essential access to HIV test counseling, linkage-to-care support, adherence counseling, peer support, and navigation. Effective training in evidence-based interventions like motivational interviewing (MI) is imperative to maximize the impact of CSS in enhancing HIV care outcomes. MI is a collaborative, goal-oriented communication method aimed at bolstering an individual’s motivation and movement toward specific goals by eliciting and exploring personal arguments for change. MI has demonstrated efficacy across various medical and mental health outcomes, including its significant impact on the status-neutral HIV Care Continuum. Objective: The objective of this study is to develop and pilot an interactive internet-based MI training program for HIV counseling support staff (iMI4HIV), aiming to enhance their communication skills in HIV care interactions. Methods: The iMI4HIV Study will have 2 phases. In phase 1, Development, we will conduct formative focus groups (FGs) with CSS (n=16) to identify HIV care interactions for demonstration videos and to assess acceptability of gamification components; create MI demonstration videos depicting key interactions from status-neutral HIV Care Continuum; program iMI4HIV (including skills development tasks, gamification components, etc); and pilot a virtual MI (VMI) workshop followed by iMI4HIV (n=8). We will also conduct qualitative interviews with 8 leaders from HIV care agencies to explore their use of existing online MI training programs, acceptability of iMI4HIV, and possible facilitators and impediments to its adoption for training HIV CSS. In phase 2, pilot randomized controlled trial (RCT), we will randomize 30 CSS at a 2:1 ratio (VMI workshop + iMI4HIV vs VMI workshop + waitlist control) to assess the feasibility and acceptability of iMI4HIV and to pilot the RCT processes and assessments for a future efficacy trial. We will also explore the preliminary impact of iMI4HIV on MI skills acquisition. Results: The CSS focus groups began in August 2024, and programming of the training is near completion. We plan to conduct a pilot with 8 participants by the end of 2025, to obtain feedback and conclude phase 1 of the study. The phase 2 pilot RCT is expected to be launched in February 2026, with all data collection to be completed by October 2026. Conclusions: Our pilot study aims to demonstrate the feasibility and acceptability of an internet-based MI training program for HIV CSS. If successful, this training program has the potential to enhance the delivery of evidence-based interventions in HIV care settings, ultimately improving patient outcomes and adherence to treatment protocols. Further research and larger trials will be needed to confirm these findings and refine the training approach. International Registered Report Identifier (IRRID): DERR1-10.2196/82241

Stigma toward anal sex impedes engagement in health services that are vital to Ending the HIV Epidemic. We evaluated a stigma-reduction training to build HIV worker capacity to address anal pleasure and health during HIV service encounters in China. In a sequential explanatory mixed-methods design, we assessed the training’s preliminary impact on anal health promotion activities and, based on the Theoretical Domains Framework , mechanisms of action among 51 health workers. We conducted descriptive statistics, bivariate comparisons, and thematic analyses based on pre/post-training online surveys and post-training in-depth interviews. The frequency of anal health promotion activities among the 38 participants who completed pre/post-training surveys increased by 7–8% of the scale range, but not significantly ( p -values between 0.06 and 0.08). Mechanisms for discussing anal sex ( knowledge , skills , role responsibility , self-efficacy , organizational acceptability , and positive emotions ) shifted from baseline (5%-36% range), primarily due to boosts in knowledge and skills (28% and 36%, all p < .05). Additional mechanisms of comfort addressing sexual orientation , anal health , and sex-related concerns also increased (4–14% range, all p < .05). Qualitative analysis revealed mechanistic themes of heightened empathy, weakened stereotypes, and a shift toward accepting role responsibility to discuss anal sex. Gay and bisexual workers reported notable personal growth to optimize their own anal health. Although knowledge and communication skills increased provider confidence, some participants remained hesitant to initiate discussion during HIV service encounters. For most participants the theoretically-informed training activities operated as hypothesized, to enhance mechanisms that could increase provider-initiated discussion of anal pleasure and health.

Loss to follow-up (LTFU) in high-resolution anoscopy (HRA) programs jeopardizes the procedure’s potential to help prevent anal cancer. We explored quality improvement factors to understand how to address this LTFU. Using the transtheoretical COM-B Model (Capability, Opportunity, Motivation, and Behavior) and a sequential explanatory mixed-methods design, we surveyed and interviewed 13 patients who remained engaged in HIV care but who delayed their HRA monitoring or treatment visits in the same community clinic, and 6 HRA clinicians and medical assistants. Analyses involved descriptive statistics and rapid qualitative analysis. Patients were racially, ethnically, and economically representative of the LTFU population, and were generally experienced with HRA (Mean HRA visits = 4.6, SD = 2.8, mdn = 3). Providers were experienced clinicians and medical assistants (Mean years providing HRA = 6.0, SD = 2.2). Analyses revealed two primary, related barriers: (A) motivational barriers such as physical pain, discomfort, embarrassment, and anxiety; which were largely borne from (B) opportunity barriers such as difficulties with scheduling, inconsistent after-care (particularly for pain and discomfort), anxiety-inducing exam rooms and equipment, and internalized and anticipated stigma. Capability barriers, such as limited health literacy about HRA, were less common and, like motivational barriers, linked to opportunity barriers. Participants recommended potential facilitators, including easier scheduling, standardization of pain management and after-care services, and examination room modifications to reduce anxiety. To retain HRA patients in community settings, interventions should address social and physical opportunity barriers that strongly determine motivational and capability barriers. Improving convenience, standardizing pain management, and introducing stigma interventions specific to HRA, could alleviate both motivational and capability barriers.

Background: To end the HIV epidemic, we need to better understand how to address HIV-related stigmas in healthcare settings, specifically the common theoretical bases across interventions so that we can generalize about their potential effectiveness. Purpose: We describe theory-based components of stigma interventions by identifying their functions/types, techniques, and purported mechanisms of change. Methods: This systematic review examined studies published by April 2021. We applied a transtheoretical ontology developed by the Human Behaviour Change Project, consisting of 9 intervention types (ITs), 93 behavior change techniques (BCTs), and 26 mechanisms of action (MOAs). We coded the frequency and calculated the potential effectiveness of each IT, BCT, and MOA. We evaluated study quality with a 10-item adapted tool. Results: Among the nine highest quality studies, indicated by the use of an experimental design, the highest potentially effective IT was “Persuasion” (i.e. using communication to induce emotions and/or stimulate action; 66.7%, 4/6 studies). The highest potentially effective BCTs were “Behavioral practice/rehearsal” (i.e. to increase habit and skill) and “Salience of consequences” (i.e. to make consequences of behavior more memorable; each 100%, 3/3 studies). The highest potentially effective MOAs were “Knowledge” (i.e. awareness) and “Beliefs about capabilities” (i.e. self-efficacy; each 67%, 2/3 studies). Conclusions: By applying a behavior change ontology across studies, we synthesized theory-based findings on stigma interventions. Interventions typically combined more than one IT, BCT, and MOA. Practitioners and researchers can use our findings to better understand and select theory-based components of interventions, including areas for further evaluation, to expedite ending the HIV epidemic.

Cisgender men who have sex with men (cMSM) and transgender women (TGW) are disproportionally burdened by HIV. Among these populations, HIV partner-testing is a highly acceptable harm reduction tool. Particularly, cMSM and TGW report a stronger preference for blood-based tests that include assays for multiple STIs. However, no existing research has explored how these populations negotiate blood-based testing with sexual partners. In the SMARTtest study, 48 sexually active cMSM and TGW took home dual, blood-based HIV/Syphilis kits for self- and partner-testing. After 3 months, they completed a follow-up assessment and in-depth interviews about their experiences initiating testing. Of the 42 responding participants, 27 (64%) reported that it had been “fairly” or “very easy” to raise the idea of testing with partners. Participants predominantly employed partner-conscious communication strategies, including framing the testing proposal as a mandatory, non-personal component of their participation in a research study, gradually incorporating testing mentions into discussions about sexual health, and using the kits to facilitate joint testing. Yet, 21 (44%) participants reported having sex with at least one partner they did not ask to test. Concern regarding partner reactions emerged as a significant barrier to discussing test use; similarly, many partners were averse to taking a blood-based test in the context of a casual sexual encounter. Nonetheless, these findings suggest that dual, blood-based HIV/STI rapid tests may represent acceptable harm reduction tools among similar populations of cMSM and TGW, particularly if future partner-testing research is broadened to consider key couples’ dynamics that may impact test usage.

Purpose: We sought to determine whether stigma toward anal sexuality was associated with having ever received an anal examination or anal swab among gay and bisexual men (GBM). Methods: In 2017, we conducted a cross-sectional online survey with 1513 adult cisgender GBM living in the United States. We used structural equation modeling to test whether the Anal Sex Stigma Scales (a validated measure comprising provider stigma, self-stigma, and silence) was negatively associated with lifetime receipt of anorectal examination or anal swabbing by a medical provider. The model assessed mediation by respondents' comfort discussing anal sex practices with health workers and adjusted for possible confounders. Results: As hypothesized, anal sex stigma was associated with less comfort discussing anal sex (β = −0.44, 95% confidence interval [CI]: −0.50 to −0.38, p < 0.001), and greater comfort was associated with greater likelihood of screening (β = 0.28, 95% CI: 0.19 to 0.37, p < 0.001). The model demonstrated good fit (root mean square error of approximation = 0.045, comparative fit index, and Tucker–Lewis index each = 0.99) and adjusted for everyday discrimination, social support specific to anal sex, age, income, education, medical coverage, outness, and ethnic/racial identification. Collectively, model variables accounted for 48% of the variance in screening ( p < 0.001). Conclusion: GBM who endorsed less anal sex stigma reported greater comfort discussing anal sex with health workers and were more likely to have ever received anal health screening by a medical provider. To improve anal health and cancer prevention among GBM, anal sex stigma and related discomfort discussing anal sex with health workers are targets for intervention.

Introduction: Knowledge about sexual health is a key determinant of sexual behavior among adolescent sexual minority males (ASMM). No measures exist to assess anal sex knowledge, even though anal sex is the primary route by which ASMM acquire sexually transmitted infections (STIs), including a disproportionate burden of human immunodeficiency virus (HIV). Aim: We developed a new measure as a first step toward assessing the prevalence and correlates of anal sex knowledge and potential effects of interventions to improve knowledge. Methods: Two coders independently outlined domains of knowledge within 2 sex education videos designed to address anal sex knowledge among ASMM. An initial set of 56 items, some duplicative, encompassed all domains. A larger team, including a psychometrician, then iteratively revised and reduced the set of items, and assessed construct validity via cognitive testing among ASMM (N = 4, aged 16–17 years old, 75% identifying as racial/ethnic minorities). For the final set of 10 items, factor structure and convergent and divergent validity were assessed using baseline responses to an online survey within a randomized controlled pilot trial among 154 ASMM. Open-ended questions assessed their comprehension and the acceptability of items. Outcomes: We examined correlates that we anticipated would be theoretically related (ie, the HIV Knowledge Questionnaire [HIV-KQ-18] and the STD-Knowledge Questionnaire [STD-KQ]) and theoretically distinct (ie, the Patient Health Questionnaire [PHQ-2], Generalized Anxiety Disorder scale [GAD-2], and employment status). Results: The one-factor model explained 42% of the items’ common variance and demonstrated acceptable internal reliability (Cronbach’s alpha = 0.72). The measure withstood tests of convergent and divergent validity when compared to current measures (HIV knowledge, r = 0.35 and STI knowledge, r = 0.24, both P < .05; internalizing mental health symptoms, r = -0.07 and employment status, r = 0.13, both P > .05). Few respondents found words unfamiliar or uncomfortable. Clinical Implications: A method for assessing anal sex knowledge may offer opportunities to intervene to lessen harmful sequelae of a lack of knowledge. Strength & Limitations: We developed a brief, psychometrically valid measure of anal sex knowledge. The measure may neither generalize to all anal health knowledge nor to more sexually experienced, older SMM. Conclusion: The resulting 10-item, single-factor measure, the Inventory of Anal Sex Knowledge (iASK), is psychometrically sound and addresses the lack of anal sex knowledge measures among ASMM. The iASK can function to assess the prevalence and sequelae of anal sex knowledge among ASMM as well as the impact of interventions targeting anal sex knowledge.

Testing for sexually transmitted infections (STIs) remains low among sexual and gender minority populations. We assessed STI testing history using a retrospective survey among 129 HIV-negative cisgender men who have sex with men (cMSM) and transgender women who have sex with men (tWSM) who were at high risk for STI acquisition. All participants were enrolled in a parent study on self- and partner-testing for HIV and syphilis, and reported condomless anal intercourse with multiple partners during the prior 3 months. We additionally used bivariate tests to evaluate participants’ STI testing by their history of using pre-exposure prophylaxis (PrEP). One-in-seven respondents (n = 18) reported having never tested for an STI, one-quarter (n = 33) had not tested in the past year, and two-thirds (n = 83) had never used PrEP. PrEP-naïve respondents were less likely to report recent STI testing (47% vs. 85%). “Routine doctor’s visit” was the most prevalent reason for testing, but was less common among PrEP-naïve respondents (83% vs. 100%). Testing was remarkably low given the sample’s high risk of HIV and STI infection. Findings suggest that STI testing is more frequent among those who have ever used PrEP, but the risk of selection bias warrants evaluation in a larger probability sample.