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In California and locally in Alameda County, HIV disproportionately impacts African American and Latino men who have sex with men (MSM). This study will develop and test an innovative strategy to identify MSM who are unaware of their status, have them test for HIV and for those that are positive, link them to HIV care and services. The proposed intervention will have MSM, called “seeds,” reach out to their social networks and recruit their peers to take an HIV test using a self-test kit. Seeds will be trained to deliver prevention messages that encourage their friends and peers who are at risk for HIV to take the HIV self-test. The seeds provide support through the testing process and if the peer is found to be positive, they will assist in linking the peer to HIV care and services. The use of the self-test kit has the potential to overcome many of the structural barriers to testing, such as stigma, discrimination, homophobia, privacy concerns, lack of access to care, mistrust of medical providers and wait times in clinical settings. This intervention strategy also has the potential to reach young MSM who don’t normally test, by accessing this hard-to-reach population in a place where testing can occur immediately and the men are in control of the process. The study aims to examine how well the proposed intervention identifies MSM who had been undiagnosed and how well the intervention links HIV positive MSM to care.

As HIV research and prevention efforts increasingly target gay men in relationships, situational factors such as couple serostatus and agreements about sex become central to examinations of risk. Discordant gay couples are of particular interest because the risk of HIV infection is seemingly near-at-hand. Yet, little is known about their sexual behaviors, agreements about sex, and safer sex efforts. The present study utilized longitudinal semi-structured, qualitative interviews to explore these issues among 12 discordant couples. Findings show that nearly every couple had agreements about reducing the likelihood of HIV transmission from one partner to the other. Negotiating these agreements involved establishing a level of acceptable risk, determining condom use, and employing other risk-reduction techniques, such as seropositioning and withdrawal. For half of the couples, these agreements did not involve using condoms; only two couples reported consistent condom use. Despite forgoing condoms, however, none reported seroconversion over the course of data collection. Additional issues are raised where long-term HIV prevention is concerned. Future prevention efforts with discordant couples should work with, rather than fight against, the couple’s decision to use condoms and endeavor to complement and accentuate their other safer sex efforts.

HIV in Lebanon and the Middle East is predominantly among men who have sex with men (MSM), and rates of HIV and sexual risk behavior are on the rise among young MSM (YMSM), driven in part by increased freedom of expression, social tolerance in areas such as Beirut, an influx of migration attributed to MSM refugees coming from war torn Iraq and Syria, and a flourishing sex tourism industry. At a time of political and societa upheaval across MENA, with no substantial HIV prevention programs for MSM anywhere in the region, Lebanon and MENA may be at risk for a critical surge in HIV infection in this vulnerable population. This context presents a great opportunity for an intervention like Mpowerment (MP) to make a critical impact. MP is an evidence-based community-level, structural, social and behavioral HIV prevention intervention developed for YMSM. It combines strategies for individual and community empowerment and mobilization, self-affirmation, sexual self-knowledge, and the creation of supportive social environments for YMSM. It has been widely disseminated in the U.S., but it has never been used in a Muslim-dominant setting;hence, the need for formative research to help us understand how to best tailor MP for this much understudied cultural setting that is not well understood. The gay community in Beirut has grown significantly in recent years with regard to organization, development and advocacy, making it ready to take on and be successful with a community driven intervention like MP. This 5-year project will culturally adapt and pilot MP for YMSM (age 18-29) in Beirut. Phase 1 will involve extensive formative research including innovative peer ethnography and focus groups to better understand the social networks of YMSM and how they communicate about HIV and sexual health with each other, and elicit feedback on how to culturally adapt the MP program for Beirut. In Phase 2 we will pilot specific MP components and adapt the intervention manual. Phase 3 will consist of a 2-year pilot implementation and controlled evaluation of MP to assess intervention effects on community levels of sexual risk behavior and HIV testing. Cohorts of 200 YMSM in each of Beirut and the comparison community of Jounieh will be used to evaluate intervention effects. This study is innovative in being the first implementation and evaluation of any psychosocial sexual health intervention for MSM in all of MENA, and the first study of the social network-driven MP program that will use social network (SN) methodology for evaluating and adapting the intervention. It will have impact by providing pioneering data to broaden the field's understanding of the cultural underpinnings of HIV risk behavior and how to intervene to promote HIV prevention among a highrisk group (YMSM) in a cultural setting in which very little prior work has been done. The goal of this research is to establish an evidence-based model for HIV prevention and sexual health promotion with YMSM in the Middle East and other Muslim-dominant countries.

This competing renewal application builds upon the success of our project "Relationship Factors and HIV Treatment Adherence" (R01NR010187) also known as the "Duo Project". The parent grant has been successful thus far and the process and findings have informed the aims of this renewal application. Being in a primary Relationship is generally accepted as resulting in logistic and emotional support that provides health- promoting benefits. However, there is evidence that being in a primary Relationship may result in behaviors, emotions, and conflict that may hinder Adherence to prescribed Treatment regimens. Framing our work in Social Control Theory while using dyadic data analysis and maintaining the couple as the unit of analysis will maximize our understanding of how couple interactions affect Adherence. Our work to date has documented associations between partner dynamics and Adherence and has suggested the importance of studying couples over time to best understand the dynamic interplay of Relationship Factors and ART Adherence. We are therefore now proposing to extend the work through mixed qualitative, quantitative and randomized controlled trial (RCT) methodologies. The current Phase 3 study is a cross-sectional investigation of male couples to test hypotheses of the interrelationships among individual-level variables (e.g., beliefs about Treatment efficacy, substance use, and Adherence self-efficacy) and couple-level variables (e.g., Relationship satisfaction, conflict, and adherence-specific partner support), and medication Adherence and clinical variables. To optimize the contribution to the Adherence and social Relationship literature, we propose to follow these couples with repeat assessments at 6, 12, 18 and 24 months to test longitudinal hypotheses. We will purposefully select couples for in-depth qualitative interviews to further contextualize our findings and to inform interventions. Finally, we will develop and pilot a couples-based intervention, Duo PACT (Partnership Adherence Commitment Therapy), with 32 couples (equally randomized to intervention or assessment only control) to determine feasibility, satisfaction, and to inform effect size estimates for a larger trial of the intervention. Three well- validated self-report instruments will measure Adherence to ART in all participants, and we will also use MEMS caps monitoring with those in the intervention to pilot procedures for a subsequent larger RCT. Clinical status will be assessed by ultrasensitive viral load and CD4 count assays. Significance. Findings will have clinical implications for the detection of Adherence problems and the further development, evaluation, and dissemination of interventions to improve Adherence within the couple Relationship. Study findings will also have theoretical implications for the function of social control in the context of Adherence to HIV medications within non-traditional relationships and across different serostatus configurations.

The purpose of this study is to assess the feasibility and acceptability of SHEROES, a theory-driven, culturally grounded intervention to reduce sexual risk behavior among male-to-female transgender women (transwomen) at risk for HIV acquisition or transmission. HIV prevalence estimates among this population are markedly higher than estimates for other at-risk groups, and transwomen also experience severe stigma, discrimination, alienation, poverty, and victimization. Despite elevated risk for HIV, the rates of HIV testing among transwomen are much lower than other at-risk groups, and our team's research with transwomen living with HIV indicates unique barriers to treatment uptake and antiretroviral medication adherence, which puts them at elevated risk of poor HIV-related clinical outcomes, including morbidity, mortality, and transmission of HIV to uninfected partners. There is a dire need for rigorously-evaluated interventions designed specifically to meet the unique needs of transwomen. To address this need, we developed 'Sheroes,' a group-based intervention that addresses the unifying lived experiences of HIV-positive, HIV-negative, and unknown status high-risk transwomen. SHEROES was designed in close collaboration with the transgender community and is grounded in our team's innovative Model of Gender Affirmation. While a number of investigators have observed an intense need for (and often lack of access to) gender affirmation among transgender individuals, its relationship to high-risk behavior has rarely been directly investigated. This study is a pilot randomized controlled trial (RCT) comparing the SHEROES intervention to a time- and attention-matched film-based control condition. From a projected 223 to be screened, 60 self-identified transwomen who are at least 18 years of age, of any HIV status, and reporting unprotected receptive and/or insertive anal intercourse (UAI) in the past 3 months will be stratified by HIV status and randomized to receive the 5-session SHEROES intervention or a time- and attention- matched control group. Follow-up assessments will be conducted at 3 and 6 months post-randomization. While this pilot study is not powered for a formal test of outcomes or effect size estimation, we will collect data on our primary and secondary outcomes of interest to determine feasibility and acceptability of data collection and to explore our hypotheses via preliminary analyses. We hypothesize that following intervention exposure relative to control group, SHEROES participants will report a lower mean number of unprotected sexual partners. Moreover, we will test the secondary/exploratory hypotheses that SHEROES participants will report a) higher HIV testing rates (for HIV-negative transwomen at baseline); b) higher STI testing rates (for all serostatus transwomen), and c) higher HIV medical appointment attendance and ART readiness or ART use and adherence (for HIV-positive transwomen). An additional secondary/exploratory aim is to examine mediators/mechanisms of change based on the Model of Gender Affirmation (e.g., need for gender affirmation, self-objectification) and moderators of the intervention (e.g., HIV status, drug use).