Barriers to HIV Care Among Adolescent Sexual Minority Males: Healthcare Transitions, Substance Use, and Population-Level Impact Restricted; Files & ToC

Abstract

Human Immunodeficiency Virus (HIV) remains a major public health concern for adolescent

sexual minority males (SMM) in the United States. Adolescence represents a key window of

vulnerability to lapses in HIV care, shaped by developmental, behavioral, and structural risk

factors. This dissertation characterized longitudinal patterns of HIV-related outcomes and

modeled the population-level impact of key barriers to HIV healthcare among adolescent SMM.

Aim 1: Many adolescent men with HIV navigate a transition from pediatric to adult HIV

healthcare settings, a process associated with disruptions in viral suppression but studied mostly

through qualitative methods, short follow-up periods, or data from a single care setting. Using

electronic medical records from an integrated pediatric and adult HIV clinic, we applied groupbased

trajectory modeling to explore longitudinal patterns of HIV viremia. We identified distinct

latent trajectories and found suggestive evidence that initiating the healthcare transition was

associated with lower probability of detectable viremia, particularly among those with

persistently high viral burden.

Aim 2: Substance use is common among adolescent SMM, but longitudinal patterns of use and

their associations with HIV prevention and treatment medication behaviors remain incompletely

characterized. Using longitudinal cohort data, we identified distinct and largely stable trajectories

of hazardous alcohol use, hazardous cannabis use, and non-prescription drug use. Associations

between substance use trajectories and adherence to pre-exposure prophylaxis and HIV

antiretroviral therapy varied across substance type, medication class, and modeling assumptions.

Aim 3: While individual-level effects of substance use on HIV risk behaviors are wellestablished,

their aggregate impact on population-level transmission cannot be assumed to scale

linearly. We adapted a stochastic, agent-based network model to simulate interactions between

alcohol, cannabis, and methamphetamine use and multiple HIV risk pathways among adolescent

and adult SMM. Complete cessation of substance use was associated with substantial reductions

in simulated 10-year HIV incidence.

These findings expand the evidence base linking healthcare transition processes and substance

use to HIV outcomes among adolescent SMM, and provide a foundation for future research to

design targeted interventions and evaluate their population-level impact.

Table of Contents

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About this Dissertation

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School	Laney Graduate School
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	adolescent substance use sexual minority male HIV
Committee Chair / Thesis Advisor	Samuel Jenness, Emory University
Committee Members	Sophia Hussen, Emory University Heather Bradley, Emory University Patrick Janulis, Northwestern University

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