Aaron J. Blashill, Ph.D. - US grants

DESCRIPTION (provided by applicant): This is an amended, previously well-received, K23 proposal addressing health risk behaviors in men who have sex with men (MSM) within the context of syndemics (co-occurring psychosocial problems), and a particular focus on body image disturbance and depression. MSM constitute, by far, the largest number (H60%) of individuals with HIV in the U.S. Modest effects of behavioral interventions for MSM may be because they generally do not address the unique and varied psychosocial context for this population. Study after study concludes that co-occurring syndemics contribute to poor self-care behaviors including, sexual risk and HAART non-adherence, and may interfere with uptake of interventions for MSM1-7. One example of an understudied psychosocial problem among HIV-infected MSM is dissatisfaction with one's appearance. It is estimated that 31% of HIV-infected MSM have elevated body dissatisfaction8, which is syndemic to depression, sexual transmission risk, and HAART non-adherence. CANDIDATE: I am a postdoctoral fellow at Massachusetts General Hospital/Harvard Medical School with 15 peer-reviewed publications (12 first-authored) on psychosocial problems such as body dissatisfaction and depression among MSM, HAART adherence, and HIV sexual transmission risk behaviors. The present proposal will allow me to acquire needed skills to achieve my goal of becoming an independent researcher studying co-occurring psychosocial and self-care problems among MSM living with and at risk for acquiring HIV. MENTORING: Dr. Steven Safren, the primary mentor, has expertise in addressing psychosocial problems in the context of interventions for self-care in HIV, including depression, HAART adherence, and HIV prevention. Drs. Kenneth Mayer and Sabine Wilhelm are secondary mentors and add considerable unique expertise to the mentoring team, with their respective research specializations in HIV prevention and body dissatisfaction interventions. RESEARCH: As an example of a way to integrate improving self-care behaviors while addressing an important psychosocial syndemic indicator, I will develop a novel intervention which addresses body dissatisfaction, syndemic to depression, secondary HIV prevention, and HAART adherence among HIV-infected MSM. With mentorship, this intervention will be developed through an initial iterative process, and then piloted in a randomized control trial. TRAINING: I will receive direct mentoring in addressing psychosocial problems in the context of self-care (HIV prevention and adherence), the iterative process of developing and testing interventions that focus on both psychosocial problems and self-care, as well as dissemination. This is directly tied to my primary mentor's K24 award (and his other grants), on which I can be part of, and observe the iterative intervention development related to syndemics. I will also receive training in advanced statistical analysis, take courses on clinical trials, longitudinal modeling, qualitative analysis, and missing data. PUBLIC HEALTH RELEVANCE: MSM represent, by far, the largest group of individuals living with HIV in the U.S., and for public health interventions to be effective with this population, the will need to address the real-life set of psychosocial problems that this group faces. In addition to quality of life concerns, studying the role of body dissatisfaction is relevant for the treatmen of depression, as well as secondary prevention and management of HIV, as body dissatisfaction has been linked to increased depression, sexual transmission risk and HAART non-adherence. However, to date, no intervention exists which incorporates body dissatisfaction into HIV-care with MSM.

Project Summary/Abstract Eating disorders are resistant to treatment and associated with significant morbidity and mortality. Thus, efficacious and efficient eating disorder prevention programs are greatly needed. There has been a longstanding belief among the general public, and clinicians, that eating disorders are nearly an exclusively female problem. However, extant literature has found that males also experience eating disorders, constituting up to 40% of individuals with diagnostic/sub-threshold eating pathology. Among males, sexual minorities (i.e., gay, bisexual, and non-heterosexual identified individuals) are a salient subgroup that is at substantial risk for developing eating disorders. Indeed, sexual minority males are not only at elevated risk compared to heterosexual males, but are also at elevated risk compared to heterosexual females. The lifetime prevalence for any eating disorder diagnosis among sexual minority males is 8.8%, and subclinical diagnosis is 15.6%. This is in contrast to heterosexual females, in which the prevalence for clinical and subclinical diagnoses are at 4.8% and 8.0%, respectively. These findings indicate that sexual minority males may well be one of the most vulnerable groups in regard to eating pathology risk. To date, there is a paucity of research on eating disorder prevention programs among sexual minority males. We are only aware of one previous prevention program targeting sexual minority males. This program, the PRIDE Body Project, developed and tested by our research team, is a two-session, peer co-led, group, cognitive dissonance-based eating disorder prevention program, based on existing eating disorder prevention programs developed with females. In our preliminary randomized controlled trial (RCT), we found significant and large effects on eating pathology and relevant eating disorder risk factors, compared to a waitlist control condition, at post-treatment and 4-weeks post-treatment. Additionally, preliminary mediation analyses revealed that internalization of the appearance ideal and body dissatisfaction accounted for significant variance in the relationship between treatment condition and eating pathology. These results represent an important first step in demonstrating the acceptability, feasibility, and preliminary efficacy of a brief, peer-led eating disorder prevention program for sexual minority males. Despite these initial findings, future research is needed to further test this promising intervention. Specifically, it is not known if the PRIDE Body Project will exert a clinically and statistically significant effect in comparison to a time and attention matched control condition. Additionally, it is unknown if the intervention effects will persist beyond 4-weeks post intervention. With these limitations in mind, we propose to conduct a randomized controlled trial assessing the PRIDE Body Project to a time and attention-matched active control condition, and follow participants for 24 months. Additionally, we plan to assess potential mediators (body dissatisfaction and internalization of the appearance ideal) of the treatment effect on eating disorder symptoms.

PROJECT SUMMARY Men who have sex with men (MSM) are the most at-risk group for contracting human immunodeficiency virus (HIV) in the U.S., comprising 67% of new HIV diagnoses in 2014. However, the HIV epidemic impacts some groups of MSM disproportionately. Latino MSM comprise 25.1% of new HIV infections among MSM between the ages of 13 and 29 years. The daily medication tenofovir/emtricitabine was approved by the Food and Drug Administration for pre-exposure prophylaxis (PrEP) in 2012 and has demonstrated strong efficacy in reducing the risk of HIV infection. When taken consistently, PrEP has been shown to reduce new incidence of HIV by 92%. Despite the promise of PrEP to transform HIV prevention, there remain significant barriers to PrEP use among those who would benefit the most, resulting in low rates of uptake. Although Latino MSM have reported the lowest use of PrEP (6.6%), they also reported the greatest willingness to use PrEP compared to White and Black MSM. There have been no known interventions that have been designed to assist Latino MSM with accessing PrEP-related health care or adhering to PrEP. Patient navigation may be an ideal intervention to aid in PrEP uptake among Latino MSM by assisting individuals in overcoming barriers to obtaining and using PrEP. To our knowledge, no known patient navigation programs for PrEP have been developed for Latino MSM. The objectives of this proposed study are to develop, pretest, produce, and pilot test a patient navigation intervention designed to address multiple components of the PrEP cascade among Latino MSM between the age of 18 and 29. During Phase 1, qualitative data will be collected through 30 in-depth interviews to assess needs and assets of young adult Latino MSM regarding engagement and retention in the PrEP cascade. From these findings, health care provider and staff feedback, and through the guidance of a Participatory Planning Group, a patient navigation intervention will be developed and pre-tested through 25 in-depth interviews. During Phase 2, the patient navigation intervention will be pilot-tested with 60 young adult Latino MSM. The patient navigation intervention will be compared to usual care plus written information to evaluate the feasibility and acceptability of the intervention and study methods, as well as the intervention's potential in improving engagement and retention in PrEP-related care. The project will investigate the following specific aims: 1) to assess the needs and assets of young adult Latino MSM regarding engagement and retention in the PrEP cascade; 2) to develop, pretest, and produce a patient navigation intervention designed to facilitate engagement and retention in the PrEP cascade among young adult Latino MSM; and 3) to conduct a pilot randomized controlled trial of the patient navigation intervention by comparing it to usual care to assess feasibility, acceptability, and preliminary impact. The proposed study has significant public health implications and is expected to contribute to efforts to reduce HIV-related disparities and increase adherence to PrEP.

PROJECT SUMMARY Suicide is the 10th leading cause of death among all U.S. citizens and is the 2nd leading cause of death among youth and emerging adults between the ages of 15 and 29. One group that is particularly vulnerable to suicide is sexual and gender minorities (SGMs). SGM is an umbrella term used to describe individuals who identify as non-exclusively heterosexual (e.g., gay, lesbian, bisexual) and/or as transgender/non-binary (e.g., identify as a gender different from their birth sex). Indeed, recent U.S. representative findings from 2017 underscore striking disparities in suicidality between sexual minority and heterosexual adolescents, with 23% of sexual minority youth reporting one or more suicide attempts (in the past 12 months) vs. 5.4% of heterosexual youth. Prevalence of lifetime suicide attempts among gender minorities is also substantially elevated compared to the general population, with 45% of 18-24-year-old transgender individuals reporting a history of one more suicide attempts. Despite these substantial health disparities in suicide among SGM youth/emerging adults, no known suicide prevention programs exist for this highly vulnerable population. Given this crucial gap in the literature, the proposed study will adapt and test an innovative intervention that integrates patient navigation with the Safety Planning Intervention (PN+SPI) for SGM youth/emerging adults designed to target mechanisms (e.g., reductions in thwarted belongingness and increases in suicide-related coping skills) that theoretically underlie suicide. If the PN+SPI intervention displays a clinically meaningful effect on the purported targets (i.e., reductions in thwarted belongingness and increases in suicide-related coping skills) during the open-phase trial (R61 phase) and is feasible and acceptable, we will subsequently move to the R33 phase. In the R33 phase, we will conduct a pilot randomized controlled trial of the PN+SPI by comparing it to SPI alone to assess feasibility, acceptability, and preliminary efficacy. During the randomized controlled trial, in which we will sample 170 youth and emerging adult SGMs, we will also evaluate the mechanisms of action of the PN+SPI intervention through longitudinal analysis. The proposed project has substantial public health significance as SGMs are one of the most vulnerable groups for suicidality globally. Given the brevity of the PN+SPI intervention and its emphasis on safety planning and accessing community resources, the PN+SPI intervention has high potential for wide dissemination and public health impact.