H Jonathon Rendina, PhD, MPH - US grants

DESCRIPTION (provided by applicant): The numbers of men who have sex with men who are HIV-positive in the United States continues to rise, particularly in large urban centers such as New York City. As such, unique approaches to assessing psychosocial and sexual health and well-being of HIV-positive gay and bisexual men are crucial to developing interventions tailored to reducing sexual risk and substance use in this population. Disclosure of HIV status remains difficult for HIV-positive people due to stigma, and this difficulty is especially apparent within sexual situations. Both status disclosure and substance use have been investigated in prior research as variables that increase sexual risk (i.e. sex without condoms) among HIV-positive gay and bisexual men. During sexual encounters with non-main (i.e. new or casual) sexual partners, cognitive conflicts that result from fear of interpersonal rejection and intrapersonal shame are likely to influence the synergistic relationship between disclosure, substance use, and condom use. Building on the social psychological theory of cognitive dissonance, this investigation is based on a hypothesis that dissonance (i.e. conflict) is a negative state of arousal that motivates people to engage in behaviors to reduce that negative arousal. We hypothesize that interpersonal conflict (i.e., fear of being rejected for disclosing HIV-positive status and for using condoms) and intrapersonal conflict (i.e., higher levels of sexual shame) will interact to increase substance use and decrease both condom use and disclosure within sexual encounters. The primary goal of this study is to provide useful measurements of these constructs and examine these hypotheses to inform public health interventions aimed at reducing sexual risk and substance use. As such, the project focuses on two aims: (1) to establish reliability, validity, factor structure, and psychometric properties of three measures of intrapersonal and interpersonal conflict; and (2) to elaborate and test the relationship of interpersonal and intrapersonal conflict with HIV status disclosure, sexual risk, and substance use during sex with casual partners. The proposed project will be embedded into a larger study (R01MH87714, Parsons PI; referred to herein as the parent project), which is a longitudinal study that follows highly sexually active gay and bisexual men utilizing multiple methods to investigate their sexual risk behavior. The proposed project will add two internet-based assessments to the parent project that include both new and existing measures. We will combine these new measures with existing data to examine the psychometrics of the newly created measures and test the significance of the proposed hypotheses. The research and training plans proposed for this project are also designed to foster my development as a research scientist with a strong foundation in sexual risk, substance use, and research with HIV-positive gay and bisexual men. PUBLIC HEALTH RELEVANCE: This project was designed to investigate the synergistic relationship between substance use, status disclosure, and condom use as they influence HIV transmission risk among HIV-positive gay and bisexual men. Utilizing a framework based in the validated theory of cognitive dissonance, this study will enhance our understanding of how interpersonal and intrapersonal conflicts may interact to increase or inhibit transmission risk behaviors. A better understanding of the role of cognitive conflicts in influencing risk behavior will be essential to the development of future HIV prevention efforts with HIV-positive gay and bisexual men.

? DESCRIPTION: Gay and bisexual men (GBM) and other men who have sex with men (MSM) continue to be disproportionately affected by the HIV epidemic. Though minority stress models of health have been investigated for GBM in general, such models that incorporate the unique role of HIV-related stressors for HIV- positive GBM have yet to be tested. Research suggests that HIV-related stressors are associated with emotion regulation and health risk behaviors and that emotion regulation may be one path through which stressors impact behavioral outcomes. Moreover, neurocognitive functioning has been found to be associated with both emotion regulation and health risk behaviors (e.g., substance use, sexual risk, and medication non-adherence) as well as with the efficacy of behavioral interventions aimed at reducing health risk behavior. This Mentored Research Scientist Development Award (K01) will provide the candidate with the protected time, training, and resources necessary to carry out research aimed at applying a minority stress model to HIV-positive GBM. Specifically, the goal of this award is to test an HIV-related minority stress model of emotion regulation and health risk behavior among HIV-positive GBM and developing an intervention to target these minority stress and emotion regulation pathways. To accomplish these goals, the candidate requires training and mentorship in two areas: (1) the design of behavioral interventions and their translation to technology-based platforms; and (2) the theory and methods of behavioral and cognitive neuroscience. Training will be accomplished through a combination of didactic coursework, seminars, trainings, conferences, and mentored research projects. The overarching aims of these research projects are to: (1) conduct secondary data analyses to test an HIV-related minority stress model whereby HIV-related stressors lead to poorer emotion regulation which is associated with neurocognitive functioning and leads to health risk behavior and HIV-related health outcomes; (2) conduct a pilot study utilizing ecological momentary assessment (EMA) to develop a measure of situational (i.e., daily) HIV-related minority stressors and gather preliminary data on its association with neurocognitive functioning and daily experiences of emotion regulation difficulties, sexual risk behavior, substance use (i.e., alcohol and club drug use/abuse), and medication adherence; and (3) develop and pilot test for feasibility and acceptability an EMA-based behavioral intervention aimed at managing the impact of HIV-related minority stressors on emotion regulation, substance use, sexual risk behavior, medication adherence, and health outcomes. Together, these research projects will address novel questions about the role of HIV-related stressors in the health of HIV-positive GBM, provide modifiable targets for intervention, examine preliminary estimates of feasibility and acceptability of a mobile intervention to address these targets, and explore the role that neurocognitive functioning plays within the model. The training and research plan will allow the candidate to develop into an independent investigator focusing on creating innovative and high-impact interventions to address substance use, sexual risk, and HIV medication adherence for HIV-positive GBM.

Project Summary Gay, bisexual and other men who have sex with men (GBMSM) remain a population in the U.S. for whom the burden of HIV is high and disproportionate, particularly among younger GBMSM and GBMSM of color, for whom HIV incidence continues to rise despite decades of HIV prevention research to curb the epidemic. However, even among these highest risk groups, risk for infection is not equivalent and the goal of this study is to better understand what factors differentiate levels of risk for HIV infection. Research to date suggests that this disproportionate burden is likely to be exacerbated by psychosocial disparities faced by this population in the form of syndemics and sexual minority stress. However, research on these factors has been limited by a focus on risk for HIV infection operationalized as risk behavior or cross-sectional prevalence of HIV, making actual vulnerability to infection and temporal associations difficult, if not impossible, to determine. We are submitting this application in response to RFA-AI-16-031 Limited Interaction Targeted Epidemiology (LITE) to Advance HIV Prevention (UG3/UH3). We propose to recruit and enroll a large and diverse cohort of approximately 8,000 GBMSM ages 16 and older in the U.S. and Puerto Rico who are at high risk for infection. We will utilize mobile sexual networking applications (?mobile apps?) to identify and enroll these men both to allow for rapid and efficient recruitment and because these apps rapidly increasing in popularity, with research demonstrating that men who use mobile apps are at higher levels of risk for HIV infection than GBMSM recruited through other means. Using this cohort, we will work to achieve three primary aims: (1) we will establish HIV prevalence as well as prevalence of rectal sexually transmitted infections (STIs; gonorrhea and chlamydia) at baseline and subsequently establish rates of HIV and rectal STI incidence among these men 12 months thereafter; (2) we will utilize baseline levels of syndemic, minority stress, and other relevant psychosocial risk factors to develop a model of those modifiable factors that contribute to increased risk for HIV seroconversion (i.e., incidence) as well as rectal STI infection; (3) we will utilize the model to target men in the highest quartile of risk for HIV seroconversion in the cohort and follow them every 6 months thereafter for an additional two years to examine the predictive utility in prospectively predicting HIV seroconversion as well as time to seroconversion. Developing a model of modifiable psychosocial risk factors for actual HIV seroconversion and subsequently testing its reliability and validity in a prospective design has high potential to improve the next generation of HIV prevention interventions aimed at reducing disparities for this population.

Project Summary Gay and bisexual men (GBM) in the U.S. are burdened by a high and disproportionate rate of HIV infection and more than half of all HIV+ individuals are GBM. Improving viral load (VL) suppression is associated with a significant reduction in the sexual transmission of HIV. Moreover, research is needed to better understand the modifiable social and behavioral factors that influence their long-term health. Chronic experiences of sexual minority stressors (e.g., internalized homonegativity) have been shown to influence a variety of mental, behavioral, and physical health outcomes for GBM, including general stress (e.g., cortisol) and immune (e.g., cytokines) outcomes, as well as HIV-specific health outcomes (e.g., CD4 count) among HIV+ GBM. Chronic experiences of HIV-related stressors have also been shown to impact mental health and health behaviors for HIV+ GBM, though there is substantially less research on their role in the health of HIV+ GBM. Previous research, including our own, has shown that fluctuations in sexual minority and HIV-specific stressors (i.e., acute experiences of these stressors) are measurable and meaningfully associated with health outcomes. Both HIV infection and substance use are associated with declines in neurocognitive function and emerging evidence suggests that emotional processing may help explain the impact of psychological phenomena on health outcomes. To develop interventions that are robust and durable, research is needed that examines the unique and overlapping influence of sexual minority and HIV-related stressors on health outcomes for HIV+ GBM within a unified biopsychosocial model. Such a model should take into account both individual-level (i.e., chronic) and situational (i.e., acute) experiences of these stressors to examine their independent associations with health, and should consider whether emotional interference in cognitive processing might moderate these associations. Aim 1 of the study is to test a biopsychosocial model of sexual minority and HIV-related stress and health, examining direct and indirect effects of these stressors on each outcome. Aim 2 is to test the moderating role of emotional interference in cognitive processing on these associations. Finally, Aim 3 is to examine the extent of intraindividual variability over one year in sexual minority and HIV-related stressors, VL, CD4, and cytokines. Although not an aim, the study will culminate in the development of guidelines for future intervention development and we will gather participant feedback on these recommendations. To accomplish these aims, we will enroll 250 HIV+ GBM and follow them for 12 months. We will use ecological momentary assessment (EMA) for 21 days and quarterly longitudinal follow-ups over one year to test the impact of sexual minority and HIV-related stress on physiological stress (diurnal cortisol) and long-term immune outcomes (VL suppression, CD4 count, cytokines). This study will address novel questions about the relative role of sexual minority and HIV-related stress in the health of HIV+ GBM to guide the development of interventions to improve health and reduce HIV transmission, morbidity, and mortality among HIV+ GBM.

Project Summary Gay, bisexual, and other sexual minority men (SMM) are the group most impacted by the domestic HIV epidemic. Critically, these rates are highest among young SMM (YSMM), with Black, Latino, and White YSMM under age 35 being the three groups with the highest rates of new HIV diagnoses in 2016. Although more is known about sexual minority stigma (i.e., internalized homonegativity), little quantitative work has focused on intersectional experiences of stigma for diverse YSMM. Compared to White YSMM, intersectionality theory suggests that increased HIV incidence among Black and Latino YSMM may due in part to the distinct effects of stigma that occurs at the intersection of their multiple stigmatized identities. Researchers have consistently found that exposure to sexual minority stigma at least partially explains the disproportionate experience of adverse mental and physical health outcomes for SMM compared to the general population, though the literature on intersectional stigma and HIV prevention for YSMM is less well developed. Experiences of stigma occur regularly and are shaped by the context in which they occur, and event-level methodologies may be an ideal way to collect such data. Although a few event-level studies of stigma have been published, few if any have used rigorously developed, community-informed, and psychometrically validated items. To address these limitations of the literature to date, the goal of this research is to conduct a three-phase study to generate, refine, and optimize event-level measures of stigma for Black, Latino, and White YSMM aged 16-29 that focus on the intersection of race, ethnicity, sexual minority identity, and gender performance (i.e., masculinity). The first aim of the study is to generate and refine an item pool using the available literature and interviews with expert researchers and community members (Phase 1) followed by an iterative process of cognitive interviewing and pilot testing of the items with YSMM themselves (Phase 2). Having generated an item pool, the second aim of the study is to use the items to conduct a 21-day daily diary study with 150 YSMM (Phase 3) to examine the psychometric properties of the items, reduce the item pool, and test the predictive validity of the items for three HIV prevention outcomes?HIV testing, STI testing, and rectal STI infection. To enroll YSMM for Phases 2 and 3, we will leverage an existing cohort to rapidly recruit participants; in Phase 3, we will also gather data collected during the cohort study both prior to and following the 21-day diary study. The proposed study will address a notable gap in the literature by systematically developing and optimizing items to capture event-level experiences of intersectional stigma for diverse YSMM across the U.S. Overall, the final item pool developed will help to further research on intersectional stigma and health disparities; generating items with greater cultural relevance and lower measurement error will enhance power to detect meaningful intervention effects in future research aiming to reduce intersectional stigma and disparities in HIV incidence for YSMM.

Project Summary Gay and bisexual men and other sexual minority men (SMM) in the U.S. are burdened by a high and disproportionate rate of HIV infection. Improving outcomes of the HIV Care Continuum through to maintaining viral load (VL) suppression is associated with a significant reduction in the sexual transmission of HIV and significantly better long-term health outcomes. However, little research provides insight into the preventable structural, psychosocial, and behavioral factors that influence durable VL suppression during early infection that can be used in developing effective early intervention strategies. Moreover, the successful implementation of TasP and U=U messaging is a necessary component of the strategy to end the HIV epidemic, but rigorous research is needed to address real-world implementation issues, including safety concerns and perceived barriers among key stakeholder populations. We aim to address these issues with two studies grounded in the Social Ecological Model (SEM) to simultaneously examine both VL suppression and implementation barriers surrounding U=U from multiple levels of influence. Specifically, Aim 1 of the study is to examine time to initial VL suppression and patterns in VL rebound to better understand the dynamic nature of VL suppression and use the SEM along with an intersectional minority stress framework to longitudinally investigate structural, psychosocial, and behavioral factors associated with VL suppression among SMM to better understand risk and resilience. Next, Aim 2 is to examine how adherence and perceived VL status are associated with objective VL status and whether concordance between perceived and actual VL suppression influences sexual risk compensation as captured by event-level sexual behaviors and STI infections. Finally, Aim 3 is designed to understand ongoing barriers to implementing U=U from the perspectives of the three populations critical to its successful implementation among SMM?namely, SMM living with HIV, HIV-negative SMM, and HIV care providers. To do so, Study 1 (Aims 1 and 2) will leverage two LITE cohorts to recruit 250 SMM newly diagnosed with HIV during the course of the studies?we will follow these men for two years immediately following diagnosis, collecting home-based dried blood spot for VL on a monthly basis to examine the dynamic nature of VL suppression. In addition to VL and self-reported data, the study will include objective indicators of adherence and care engagement as well as qualitative interviews. The goal of Study 1 will be to identify risk and resilience factors that influence VL suppression and can be used to guide future intervention development (Aim 1) while simultaneously addressing understudied safety concerns of implementing U=U with regard to unintended risks (Aim 2). In Study 2 (Aim 3), we will use focus groups conducted three times over five years to inform implementation of U=U messaging. Achieving the aims of the proposed study will provide key insights that will be critical for translating to or adapting interventions to enhance their potency and durability and improve the health of SMM living with HIV and curb new infections.