Understanding the Intersecting Impact of Stigma, Mental Health Disorders and Poverty on PrEP Use and HIV Incidence Among Cis-Gender Men Who Have Sex with Men in the United States Restricted; Files Only
Onwubiko, Udodirim N. (Summer 2024)
Abstract
Pre-exposure prophylaxis (PrEP) effectively reduces HIV acquisition risk among gay, bisexual, and other men who have sex with men (MSM) who are disproportionately affected by HIV in the United States (US). However, PrEP uptake remains inconsistent among MSM, influenced by psychosocial factors such as sexual stigma, mental health, and poverty. Understanding these influences and their interactions is crucial for the effective design of interventions to optimize PrEP use. The overarching goal of this dissertation was to investigate how sexual stigma, mental distress, and poverty collectively influence PrEP utilization among US MSM, and how an integrated intervention addressing these factors could impact HIV incidence.
The first study examined variations in sexual stigma experiences among HIV-negative MSM and their associations with mental health outcomes, including mental distress and suicide-related issues, while considering poverty status. Four distinct patterns of sexual stigma experiences were identified, with statistically significant associations between these patterns and mental health outcomes, particularly among those facing poverty.
The second study evaluated the individual and combined associations of mental distress and sexual stigma with PrEP engagement (initiation, adherence, and persistence) among MSM eligible for PrEP. Nuanced associations were found across stigma-mental distress groups, with stronger adverse associations observed among individuals experiencing both sexual stigma and mental distress.
In the third study, we analyzed electronic health records of MSM starting daily oral PrEP at three sexual health clinics in Boston, MA, assessing whether a baseline depression diagnosis impacted daily oral PrEP discontinuation rates within the first 18 months after initiation. High rates of PrEP discontinuation were observed, especially early after initiation, with individuals diagnosed with baseline depression showing a modest but statistically significant higher rate of discontinuation compared to those without a depression diagnosis.
The final study utilized dynamic HIV transmission network models to estimate the population-level impact of integrating resilience-building mental health care alongside PrEP on HIV incidence among MSM. Findings revealed nuanced impacts, indicating the need for simultaneous enhancements in other risk-reduction strategies alongside mental healthcare integration with PrEP to appreciably reduce HIV incidence among US MSM.
This dissertation highlights the roles psychosocial factors play in shaping PrEP engagement among MSM. Integrating mental healthcare into PrEP holds promise for optimizing mental health and concurrently addressing PrEP usage barriers among MSM, but additional strategies are necessary to achieve substantial reductions in HIV incidence.
Table of Contents
Chapter 1 Project Overview and Background.. 11
1.1. Overview.. 11
1.2. Background.. 11
1.2.1. Defining Stigma and Understanding Its Manifestations. 12
1.2.2. Stigma Measurement in Literature and Its Impacts on PrEP Engagement 13
1.2.3. Mental Health in the United States. 15
1.2.4. Mental Health Impacts on PrEP Use. 16
1.2.5. Socio-economic Inequalities as a key driver of health disparity. 16
1.2.6. Linking Sexual Stigma, Mental Health, and Poverty. 17
1.3. Dissertation Rationale. 17
1.4. Overarching Goal and Specific Aims. 19
Chapter 2 Population Heterogeneities in Sexual Stigma Experiences Among US MSM and Links to Mental Health Outcomes Within the Context of Poverty. 20
2.1. Introduction.. 21
2.2. Methods. 22
2.2.1. Data Source and Study Eligibility. 22
2.2.2. Measures. 23
2.2.3. Statistical Analyses. 24
2.3. Results. 25
2.3.1. Sample Description & Sexual Stigma Experience Endorsement 25
2.3.2. Latent Sexual Stigma Classes. 27
2.3.3. Sociodemographic Factors Associated with Stigma Class Membership. 34
2.3.4. Sexual Stigma Association with Mental Health Outcomes. 34
2.3.5. Quantification of Sexual Stigma and Poverty Interaction. 35
2.4. Discussion.. 35
2.4.1. Limitations. 37
Chapter 3 Assessment of Individual & Joint Associations of Sexual Stigma and Mental Distress with PrEP Engagement Among US MSM with PrEP Indications. 38
3.1. Introduction.. 39
3.2. Methods. 41
3.2.1 Data Source and Study Eligibility. 41
3.2.2. Measures. 41
3.2.3. Statistical analyses. 42
3.3. Results. 44
3.3.1. Study Sample Description. 44
3.3.2. Latent Sexual Stigma Classes. 44
3.3.3. PrEP Engagement Patterns and Variations by Psychosocial Characteristics. 53
3.3.4. Individual Associations of Sexual Stigma and Mental Distress with PrEP Engagement 53
3.3.5. Joint Associations of Sexual Stigma and Mental Distress with PrEP Engagement 53
3.4. Discussion.. 54
3.4.1.Limitations. 57
Chapter 4 Baseline Depression Diagnosis and Sustained PrEP Use Among MSM: A Study of the First 18 Months of Daily Oral PrEP Initiation for HIV Prevention.. 59
4.1 Background.. 60
4.2 Methods. 61
4.2.1 Data Source and Study Eligibility. 61
4.2.2. Measures. 62
4.2.3. Statistical Analysis. 63
4.3. Results. 65
4.3.1. Study Sample Description. 65
4.3.2. PrEP Discontinuations and Trends Over Time. 66
4.3.3. Competing PrEP Discontinuation Events & Associations with Baseline Depression. 68
4.3.5. Sensitivity Analyses Findings. 74
4.4. Discussion.. 74
4.4.1. Limitations. 77
Chapter 5 Intervening on Sexual Stigma and Mental Health to Improve PrEP engagement among MSM 78
5.1 Background.. 79
5.2. Methods. 81
5.2.1. Study Design. 81
5.2.2. Base Model and Data Sources. 81
5.2.3. Intervention Models. 83
5.2.4. Model calibration, Simulation and Outcomes. 84
5.3. Results. 85
5.4. Discussion.. 90
5.4.1 Limitations. 92
Conclusions and Public health Implications. 94
References. 99
Appendix. 122
Supplemental Tables and Figures 127
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File download under embargo until 21 August 2030 | 2024-06-26 11:42:27 -0400 | File download under embargo until 21 August 2030 |
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